The Leapfrog Hospital Survey
Reference Book
Supporting Documentation for the
2011 Leapfrog Hospital Survey
December 13, 2011
v5.3.4
2011 Leapfrog Hospital Survey Reference Book
Table of Contents
Table of Contents
TABLE OF CONTENTS ........................................................................................................................ 2
SURVEY OVERVIEW AND SECTION 1: BASIC HOSPITAL INFORMATION ................................. 6
WHAT’S NEW IN THE 2011 SURVEY ........................................................................................................... 6
CHANGE SUMMARY SINCE RELEASE .......................................................................................................... 7
FREQUENTLY ASKED QUESTIONS (FAQS) ................................................................................................. 7
Development of Survey ........................................................................................................................ 7
Process for Completing the Survey ..................................................................................................... 7
Intended Use of Hospital Responses ................................................................................................. 10
Regional Roll-Out of Survey .............................................................................................................. 11
Leapfrog Hospital Recognition Program ........................................................................................... 11
SECTION 2: 2011 COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) LEAP ........................ 14
WHAT’S NEW IN THE 2011 SURVEY ......................................................................................................... 14
CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 14
CPOE FREQUENTLY ASKED QUESTIONS (FAQS) .................................................................................... 14
CPOE SCORING ALGORITHM ................................................................................................................... 16
SECTION 3: 2011 EVIDENCE-BASED HOSPITAL REFERRAL (EBHR) LEAP ............................. 17
WHAT’S NEW IN THE 2011 SURVEY ......................................................................................................... 17
CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 17
EBHR REPORTING TIME PERIODS .......................................................................................................... 18
EBHR GENERAL INFORMATION .............................................................................................................. 20
EBHR Frequently Asked Questions (FAQs) ..................................................................................... 20
General Questions .......................................................................................................................................... 20
Process Measures............................................................................................................................................ 21
EBHR Scoring Algorithm ................................................................................................................... 22
Quality Score (General) .................................................................................................................................. 22
Quality Score (Survival Predictor) ................................................................................................................. 23
CABG MEASURE REFERENCES ............................................................................................................... 24
CABG Volume: Survey p.16 .............................................................................................................. 24
Q.1: All patients undergoing procedure ......................................................................................................... 24
Q.2: Patients with an isolated CABG procedure ........................................................................................... 25
CABG Outcomes Specifications: Survey p.16 .................................................................................. 26
Q. 4 - 7: Instructions for National Performance Measurement Reporting ................................................... 26
General State Instructions (For hospitals in CA, MA, NJ, NY and PA only) .............................................. 26
State Specific Instructions ............................................................................................................................. 27
Instructions for Regional Registries .............................................................................................................. 29
CABG Process Measure Specifications: Survey p.18 ...................................................................... 30
CABG Resource Utilization Specifications: Survey p.19 ................................................................ 39
Isolated CABG Case Count ............................................................................................................................ 39
Readmission Rate ........................................................................................................................................... 41
Geometric Mean Length of Stay .................................................................................................................... 42
CABG Case Counts by Risk Factor ................................................................................................................ 44
CABG Risk Factor Definitions ....................................................................................................................... 44
CABG Frequently Asked Questions (FAQs) ..................................................................................... 46
Outcome Measures ......................................................................................................................................... 46
Process Measures............................................................................................................................................ 46
CABG Scoring Algorithm ................................................................................................................... 48
Quality Score................................................................................................................................................... 48
Resource Utilization Score ............................................................................................................................. 48
Overall Efficiency Score (also applied to PCI, AMI and Pneumonia) .......................................................... 50
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PCI MEASURE REFERENCES ................................................................................................................... 52
PCI Volume: Survey p.20 .................................................................................................................. 52
Q.1: All patients (inpatients and outpatients)undergoing PCI procedure ................................................... 52
Q.2: All inpatients undergoing the procedure ............................................................................................... 53
PCI Outcomes Specifications: Survey p.20 ...................................................................................... 53
Q. 4-7: Instructions for National Performance Measurement Reporting ..................................................... 53
General State Instructions (For hospitals in MA and NY only) ................................................................... 53
State Specific Instructions ............................................................................................................................. 54
Instructions for Regional Registries .............................................................................................................. 55
PCI Process Measure Specifications: Survey p.22 .......................................................................... 56
PCI Resource Utilization Specifications: Survey p.23 .................................................................... 58
PCI Case Count............................................................................................................................................... 58
Readmission Rate ........................................................................................................................................... 58
Geometric Mean Length of Stay .................................................................................................................... 58
PCI Case Counts by Risk Factor .................................................................................................................... 58
PCI Risk Factor Definitions ........................................................................................................................... 59
PCI Frequently Asked Questions (FAQs) ......................................................................................... 62
PCI Scoring Algorithm ....................................................................................................................... 63
Quality Score................................................................................................................................................... 63
Resource Utilization Score ............................................................................................................................. 63
Overall Efficiency Score ................................................................................................................................. 63
AVR MEASURE REFERENCES .................................................................................................................. 65
AVR Volume Standard: Survey p.24 ................................................................................................ 65
Q.1: All patients undergoing procedure ......................................................................................................... 65
AVR Outcomes Specifications: Survey p.24 ..................................................................................... 66
Q. 3 - 6: Instructions for National Performance Measurement Reporting ................................................... 66
AVR Scoring Algorithm ...................................................................................................................... 66
Quality Score................................................................................................................................................... 66
AAA MEASURE REFERENCES .................................................................................................................. 68
AAA Volume Standard: Survey p.26 ................................................................................................ 68
Q.1: All patients undergoing procedure ......................................................................................................... 68
Q.2: Patients with an unruptured AAA procedure........................................................................................ 68
AAA Process Measure Specifications: Survey p.27 ......................................................................... 69
AAA Frequently Asked Questions (FAQs) ........................................................................................ 70
Process Measures............................................................................................................................................ 70
AAA Scoring Algorithm ...................................................................................................................... 70
Quality Score................................................................................................................................................... 70
PANCREATECTOMY MEASURE REFERENCES............................................................................................ 72
Pancreatectomy Volume Standard: Survey p.28 ............................................................................. 72
Q.1: All patients undergoing procedure ......................................................................................................... 72
Q.2: Select patients in Question #1 with a diagnosis of duodenal, biliary, or pancreatic cancer ................ 73
Pancreatectomy Frequently Asked Questions (FAQs) ..................................................................... 73
Pancreatectomy Scoring Algorithm................................................................................................... 73
Quality Score................................................................................................................................................... 73
ESOPHAGECTOMY MEASURE REFERENCES ............................................................................................. 75
Esophagectomy Volume Standard: Survey p.29.............................................................................. 75
Q.1: All patients undergoing procedure ......................................................................................................... 75
Q.2: Select patients in Question #1 with a diagnosis of esophageal cancer ................................................. 75
Esophagectomy Frequently Asked Questions (FAQs) ..................................................................... 76
Esophagectomy Scoring Algorithm ................................................................................................... 76
Quality Score................................................................................................................................................... 76
BARIATRIC SURGERY MEASURE REFERENCES......................................................................................... 78
Bariatric Surgery Volume Standard: Survey p.30 .......................................................................... 78
Bariatric Surgery Frequently Asked Questions (FAQs) .................................................................. 80
Bariatric Surgery Scoring Algorithm ................................................................................................ 80
HIGH-RISK DELIVERIES MEASURE REFERENCES .................................................................................... 82
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High-Risk Deliveries Volume Standard: Survey p.31 ..................................................................... 82
High-Risk Deliveries Process Measure Specifications: Survey p.32 .............................................. 83
High-Risk Deliveries Frequently Asked Questions (FAQs)............................................................. 84
General Questions .......................................................................................................................................... 84
Process Measures............................................................................................................................................ 84
High-Risk Deliveries Scoring Algorithm .......................................................................................... 85
SECTION 4: 2011 COMMON ACUTE CONDITIONS (CAC) ............................................................ 87
WHAT’S NEW IN THE 2011 SURVEY ......................................................................................................... 87
CHANGE SUMMARY SINCE RELEASE ........................................................................................................ 87
CAC REPORTING TIME PERIODS ............................................................................................................. 88
AMI MEASURES REFERENCES................................................................................................................. 89
AMI Volume Standard: Survey p.34 ................................................................................................ 89
Q.1: All inpatient discharges with a principal diagnosis of AMI .................................................................. 89
AMI Process Measure Specifications: Survey p.34 ......................................................................... 90
AMI Resource Utilization Specifications: Survey p.35 ................................................................... 96
AMI Case Count.............................................................................................................................................. 96
AMI Readmission Rate ................................................................................................................................... 97
AMI Geometric Mean Length of Stay ............................................................................................................ 97
AMI Case Counts by Risk Factor ................................................................................................................... 97
AMI Risk Factor Definitions .......................................................................................................................... 97
AMI and Pneumonia Scoring Algorithm ........................................................................................... 99
Quality Score................................................................................................................................................... 99
Resource Utilization Score ........................................................................................................................... 102
Overall Efficiency Score ............................................................................................................................... 102
PNEUMONIA MEASURES REFERENCES .................................................................................................. 104
Pneumonia Volume Standard: Survey p.37 ................................................................................... 104
Pneumonia Process Measure Specifications: Survey p.37 ............................................................ 106
Pneumonia Resource Utilization Specifications: Survey p.38 ...................................................... 114
Pneumonia Case Count ................................................................................................................................ 114
Pneumonia Readmission Rate ..................................................................................................................... 115
Pneumonia Geometric Mean Length of Stay............................................................................................... 115
See CABG section, p.42 Rate ....................................................................................................................... 115
Pneumonia Geometric Mean Length of Stay.................................................... Error! Bookmark not defined.
Pneumonia Case Counts by Risk Factor ..................................................................................................... 115
Pneumonia Risk Factor Definitions ............................................................................................................. 115
NORMAL DELIVERIES MEASURES REFERENCES .................................................................................... 118
Normal Deliveries Volume Standard: Survey p.40 ....................................................................... 118
Normal Deliveries Outcome Measure Specifications: Survey p.40 .............................................. 118
Normal Deliveries Process Measures Specifications: Survey p.41 .............................................. 122
Normal Deliveries Frequently Asked Questions (FAQs) ............................................................... 123
Normal Deliveries Scoring Algorithm ............................................................................................. 124
SECTION 5: 2011 ICU PHYSICIAN STAFFING (IPS) LEAP ......................................................... 126
WHAT’S NEW IN THE 2011 SURVEY ....................................................................................................... 126
CHANGE SUMMARY SINCE RELEASE ...................................................................................................... 126
IPS FREQUENTLY ASKED QUESTIONS (FAQS) ...................................................................................... 126
IPS SCORING ALGORITHM ..................................................................................................................... 129
SECTION 6: 2011 LEAPFROG SAFE PRACTICES SCORE (SPS) ................................................. 131
WHAT’S NEW IN THE 2011 SURVEY ....................................................................................................... 131
CHANGE SUMMARY SINCE RELEASE ...................................................................................................... 131
SPS FREQUENTLY ASKED QUESTIONS (FAQS) ..................................................................................... 132
SPS SCORING ALGORITHM .................................................................................................................... 137
SECTION 7: MANAGING SERIOUS ERRORS ............................................................................... 141
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WHAT’S NEW IN THE 2011 SURVEY ....................................................................................................... 141
CHANGE SUMMARY SINCE RELEASE ...................................................................................................... 141
NEVER EVENTS ...................................................................................................................................... 142
Never Events Frequently Asked Questions (FAQs) ....................................................................... 142
Never Events Scoring Algorithm ..................................................................................................... 144
HAC REPORTING TIME PERIODS ........................................................................................................... 145
HAC-1: CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTIONS ...................................................... 145
HAC-1 (CLABSI) Specifications: Survey p.73 ............................................................................... 145
HAC-1 (CLABSI) Scoring Algorithm............................................................................................... 148
Summary Score ............................................................................................................................................. 148
Public Reporting ........................................................................................................................................... 150
HAC-2: HOSPITAL-ACQUIRED PRESSURE ULCER.................................................................................. 151
HAC-2 (Pressure Ulcer) Specifications: Survey p.75 .................................................................... 151
HAC-3: HOSPITAL-ACQUIRED INJURIES ............................................................................................... 153
HAC-3 (Injuries) Specifications: Survey p.76 ................................................................................ 153
HAC-2 (Pressure Ulcer) and HAC-3 (Injuries) Frequently Asked Questions (FAQs) ................. 154
HAC-2 (Pressure Ulcer) and HAC-3 (Injuries) Scoring Algorithm ............................................... 154
SECTION 8: SMOOTH PATIENT SCHEDULING .......................................................................... 156
WHAT’S NEW IN THE 2011 SURVEY ....................................................................................................... 156
CHANGE SUMMARY SINCE RELEASE ...................................................................................................... 156
SMOOTH PATIENT SCHEDULING SPECIFICATIONS ................................................................................. 157
SMOOTH PATIENT SCHEDULING FREQUENTLY ASKED QUESTIONS (FAQS) ......................................... 157
SMOOTH PATIENT SCHEDULING SCORING ALGORITHM......................................................................... 159
SECTION 9: PATIENT EXPERIENCE OF CARE ............................................................................ 161
WHAT’S NEW IN THE 2011 SURVEY ....................................................................................................... 161
CHANGE SUMMARY SINCE RELEASE ...................................................................................................... 161
HCAHPS BUNDLE SPECIFICATIONS ..................................................................................................... 162
HCAHPS BUNDLE FREQUENTLY ASKED QUESTIONS (FAQS) .............................................................. 162
HCAHPS BUNDLE SCORING ALGORITHM ............................................................................................. 163
Note: “Survey P. XX” refers to the page number(s) in the Leapfrog Hospital Survey
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Survey Overview and Section 1: Basic Hospital Information
Survey Overview and Section 1: Basic Hospital Information
What’s New in the 2011 Survey
1. Only the hospital’s organizational and contact information from the 2010 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,
2011. After that date, Leapfrog will no longer report results based on 2010 surveys submitted
prior to March 28, 2011.
2. 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 details on the desk review
process, see: http://www.leapfroggroup.org/media/file/2011SurveyResponseReviewProcess.pdf).
In addition to the desk reviews, in 2010, Leapfrog began requesting randomly selected hospitals
submit 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.
3. The research community has requested we add a hospital’s Medicare Provider Number to our
databases for easier linkages. A field has been added in the Basic Hospital Information section
for hospital’s to provide their Medicare Provider Number.
4. Hospitals are asked to optionally provide a contact in their Community Relations department for
any marketing and press coverage inquires related to your hospital’s performance on the survey.
5. Hospitals that submit a Leapfrog Hospital Survey by the June 30, 2011 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 2011 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, 2011 and an updated survey between November 1,, 2011 and December
31, 2011. For questions or more information, please contact info@leapfroggroup.org.
6. 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
2011 Leapfrog Hospital Survey, the e-mail will go to the survey contact provided in the last survey
submitted in the 2010 survey cycle.
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Change Summary since Release
None
Frequently Asked Questions (FAQs)
Development of Survey
1. How was this hospital survey developed?
This hospital survey is based on a set of hospital patient safety practices; including those that
were the initial focus of The Leapfrog Group’s efforts to promote patient safety. The Leapfrog
Group originally developed these safety practices, or Leaps, through an extensive literature
review and with input from national subject matter experts and quality researchers, in partnership
with National Committee for Quality Assurance (NCQA), The Joint Commission (TJC), Centers
for Medicare and Medicaid Services (CMS), Agency for Healthcare Research and Quality
(AHRQ), National Quality Forum (NQF) and large national purchasers. The fourth Leap
developed with the Texas Medical Institute of Technology (TMIT) addresses the updated safe
practices which were again endorsed by NQF; these national standards have been carefully
harmonized across TJC, CMS, AHRQ, the Institute for Healthcare Improvement (IHI), and AHRQ
initiatives in collaboration with each of these organizations. In addition, hospital industry
associations and individual hospital representatives provided input to this most recent survey.
The final Web survey reflects the best thinking across the industry on how to gather information
about these issues and the latest research regarding adoption of safe practices.
Process for Completing the Survey
2. Who should be involved in the process of completing the survey?
This survey requires a variety of information crossing hospital units, and as a result one person
may not have all the information readily available. We recommend that you print a hard copy of it,
review it, and then assign the survey completion to others in your organization as appropriate.
This should include someone from your quality management area who regularly compiles data
about your hospital, someone with the ability to query your hospital’s administrative data systems,
as well as representatives from your information technology group or medical staff. Before you
can complete Section 6: NQF Safe Practices, you should order a copy of the full National
Quality Forum’s Safe Practices for Better Healthcare 2010 Update: A Consensus Report
using the link on the home page of the online survey. This is an important reference you will
definitely need to complete that section.
Depending on the number of sections of the survey that are applicable to your hospital, the time
required to complete the survey will vary. Hospitals that piloted the survey and completed all
sections of the survey suggested it might take anywhere from four to six days to gather these
data depending on the number of people involved in collecting the data and the ease of access to
information for calculating the number of procedures. Once the data have been collected, the
CEO or his/her designated respondent(s) can complete the survey online, with answers in hand,
typically in less than 90 minutes.
3. What types of hospitals should complete the survey?
Acute-care, short-term general and children’s hospitals should complete the survey. The survey
was not designed for rehabilitation or psychiatric hospitals, for long-term care facilities, or for
hospitals that operate as units of other institutions, e.g., prison hospitals. Some of the NQF Safe
Practices do not apply to all hospitals. This can be indicated in the hospital’s survey responses.
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The Evidence-based Hospital Referral (EBHR) leap is applicable to rural hospitals to the extent
those services are offered (electively for EBHR) at the hospital. This can also be indicated in the
survey. Rural hospitals are welcome to respond to the survey sections dealing with Computer
Physician Order Entry (CPOE) and ICU Physician Staffing (IPS) leaps. Critical Access Hospitals
should read the instructions at the beginning of section 7 – Managing Serious Errors – and
section 9 – Patient Experience of Care - to understand which measures in these two sections are
applicable to their hospital.
4. Do any of Leapfrog safety practices apply to children’s hospitals?
Yes. Computer physician order entry (CPOE) and most of the NQF Safe Practices apply to all
children’s hospitals. The ICU Physician Staffing (IPS) leap applies to pediatric ICUs. Leapfrog’s
Never Events policy, rates of central line associated bloodstream infections (CLABSI), and
smoothing patient flow also apply to pediatric hospitals. The recently updated NQF Safe Practices
for Better Healthcare report cited above provides specific reference to children’s hospitals for
every practice.
5. In previous versions of the survey, NICUs in Children’s Hospitals reported on their census.
As a children’s hospital, can we report the number of very low birth-weight babies that we
treated?
No, unless the mother delivered her very low birth-weight (VLBW) baby in your facility. The
Evidence-based Hospital Referral (EBHR) measure is specifically for high-risk delivery of babies
considered to be in the VLBW category. Previous versions of the survey allowed NICUs located
in free standing Children’s Hospitals to submit information on census irrespective of mother’s
delivery status. In addition, hospitals must meet a volume count of VLBW babies born and treated
in their facility; this change from census to volume count of VLBW infants born and treated in the
NICU is based on the most current research.
6. What if my hospital name is different from the name that appears on the survey?
When completing the survey, right at the start you will have an opportunity to edit your hospital
name if the name that appears is incorrect.
7. What should I do if my hospital is part of a multi-hospital system? Can multi-hospital
systems fill out just one survey for all of the hospitals in the system?
If your hospital is part of a multi-hospital healthcare system, you will need to complete the survey
for each individual hospital within the system.
Variations in outcomes exist even among hospitals within the same health care system. Research
demonstrates that for Evidence-based Hospital Referral (EBHR), ICU Physician Staffing (IPS),
and Computerized Physician Order Entry (CPOE) systems, large performance variations are
demonstrated between hospitals that have these practices in place and those that do not. In
addition, if a multi-hospital healthcare system reported as one entity and there are real
differences in which hospitals have CPOE and IPS or perform high risk procedures, consumers
may be misled into thinking that the same patient safety practices are in place in all facilities.
Even in cases where hospitals’ surgical teams or individual surgeons work at more than one
facility in the hospital system or where the multi-hospital healthcare systems have the same
quality management policies and procedures, individual hospitals must report separately. If a
hospital system has two or more inpatient units which operate on separate campuses, i.e., are
not co-located or physically adjacent, they should be identified as separate hospitals for purposes
of the survey. Even if they are co-located, they should not necessarily report as one hospital. A
common medical staff is not sufficient reason to consider the hospital as one, since separate
operating units at separate facilities are likely to have different surgical teams, different
experience, and different outcomes.
Hospitals may also occasionally indicate that they are known in the community (or their marketing
objective is to create consumer recognition) at the hospital system level. Others have claimed
that “the physician makes the choice about which hospital unit is most appropriate given the
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patient’s circumstances”. These are insufficient reasons to treat multiple units as one hospital.
Since the CPOE and IPS Leaps are applied on an all-or-nothing basis, there is little reason to
combine multiple units of a system. If all units meet the standard, then each of them does.
For EBHR procedures/conditions:

If services for an EBHR-related treatment are consolidated and offered at only one unit, then
that unit should and would be the unit where patients are referred within the system and
should be identified as such to consumers.

If those services are offered at multiple units, the unit-specific experience and outcomes at
each unit are highly relevant and should be publicly reported by Leapfrog.
The test for whether a hospital is one or multiple units should be from the eyes of the consumer.
Public results from The Leapfrog Hospital Survey can help consumers make more informed
hospital choices. They should have the information that permits them to participate
knowledgeably in the selection of the hospital unit to which they are referred. See the Leapfrog
policy at http://www.leapfroggroup.org/media/file/Leapfrog-Survey_Reporting_Policy.pdf.
8. But all units in our multi-hospital share the same license and Medicare Provider Number.
How can we report as separate hospitals?
Even though hospitals are identified in The Leapfrog Hospital Survey based on their Medicare
Provider Number (MPN), a shared MPN is not a sufficient reason for reporting as one hospital in
the Leapfrog Hospital Survey. Hospitals that share a common MPN, do so because of joint billing
practices which are not relevant to the survey. The Survey Help Desk can issue additional
Leapfrog-specific MPNs to distinguish these hospitals where appropriate.
9. How frequently should my hospital respond to this survey?
Throughout the year, hospitals should resubmit their responses if and when their status changes
with regard to any of the questions. This will ensure that hospitals’ most current status is
accurately reported to The Leapfrog Group and in the results it publishes.
The Leapfrog Group revises the hospital survey on a yearly schedule designed to coincide with
most employers’ health care benefits enrollment periods and pay-for-performance reporting. We
are committed to depicting your current patient safety improvement efforts accurately to
consumers and purchasers, maintaining current information, and keeping our patient safety
recommendations up to date based on continuous input from national experts. Annual survey
revisions are planned for release each April. All publicly reported results will be replaced in early
July with results based on new surveys submitted through June 30. Public results will be updated
monthly thereafter, approximately the fifth calendar day of each month, based on surveys
(re)submitted through the end of the previous month.
10. How do I get a security code to complete the online survey?
If your hospital is one of the Regional Roll-Out areas of the U.S., the security code needed to
complete the survey online should have been sent to your hospital’s CEO by the Regional RollOut organization. See the listing of regions on the home page of the online survey and use the
link to determine if your hospital is in one of those regions. If so, call the contact for your region
indicated there; he/she can tell you where the security code was sent or send another copy of the
code to your hospital’s CEO. Your hospital CEO may have authorized the Help Desk to email a
security code to the CEO or directly to a delegate. Check with the regional contact to determine if
so. Use the code request form online to have your CEO make this delegation.
If your hospital is not in one of the roll-out areas defined there, use the link on the home page of
the online survey to request a security code and follow the instructions there.
11. I want to submit written comments with the survey. How do I do that?
We do not collect free-form text comments in the online survey. Hospitals are encouraged to
provide this additional information on their hospital Web site to inform consumers about their
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efforts in improving patient safety. Several hospitals have welcomed our suggestion that they
consider developing patient safety, or even Leapfrog-specific, content on selected pages at their
Web site, then entering the URL pointing directly to that page in the Organizational Information
section of the online survey. Consumers viewing the public results of a hospital’s survey
responses are linked to that page when they click on the little green “i’ next to the hospital’s name
on the public site.
Intended Use of Hospital Responses
12. What does The Leapfrog Group intend to do with the hospital responses to this survey?
Leapfrog purchasers agree to use the survey responses to: (1) educate and inform enrollees
about patient safety and the importance of comparing provider progress and plans regarding
Leapfrog’s safety practices; and, (2) recognize and reward providers for their progress and plans
to implement the practices. This means that purchasers will share the survey responses with their
enrollees. It also means that purchasers will use the survey results in their contracting
negotiations with plans and providers and to determine strategies for rewarding and recognizing
providers who meet Leapfrog’s safety practices. In addition, The Leapfrog Group will make all
hospital responses available to the public through various channels.
13. How will purchasers educate and inform their enrollees about the survey results?
Leapfrog purchasers plan to educate and inform enrollees about medical errors and the
importance of considering the Leapfrog safety practices in choosing a hospital. The Leapfrog
Group continues to work on enrollee communications materials that will include these broader
messages, as well as hospital-specific information based on the hospital responses to this
survey.
14. How will purchasers use the survey results in discussions with plans and providers?
Leapfrog purchasers and their health plans will use the survey results to educate and inform their
enrollees and members about local hospitals’ status vis à vis the Leapfrog safety practices,
including designating in their provider directories which hospitals meet the standards. Many
Leapfrog purchasers will also ask their health plans to help the hospitals in their networks work
toward meeting the standards. In addition, Leapfrog purchasers will use the survey results to
determine which hospitals to recognize and reward for meeting the safety practices, and which
hospitals to encourage to work toward doing so.
15. I submitted my survey. Why doesn’t the public site reflect results of my submission?
Results from surveys submitted (or re-submitted) by hospitals as of the last business day of each
month are released monthly by Leapfrog on its public site (www.leapfroggroup.org/cp) typically by
the fifth calendar day of the following month, from July through April. (No updates occur in May
and June while a new annual update of the survey is first fielded; the initial July update may be
after the fifth calendar day of the month and replaces all prior results). Other vendors that license
the Leapfrog data update their results shortly after that. Check the public site for the date through
which results have been updated.
If you completed a survey prior to the end of month and results do not appear on the public site
the next month, make sure you submitted the survey or the revised survey. A number of hospitals
have completed the survey but not clicked the Submit Survey at the bottom of the main page to
release the original or revised survey to Leapfrog. To verify the date/time and responses of the
last survey you submitted, log-on to the online survey with your security code and from the
“Survey Menu” choose View/Print Last Submitted Survey. If the date/time and answers are from
an earlier submission, you did not submit your revised survey.
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Survey Overview and Section 1: Basic Hospital Information
Regional Roll-Out of Survey
16. How is Leapfrog’s initiative being rolled out?
The Leapfrog Group’s efforts are national, but focused on a select set of regions around the
country. The “Regional Roll-Outs” are led by healthcare purchasers in healthcare markets where
there is significant Leapfrog purchaser participation, and where market characteristics are
favorable for turning Leapfrog from a purchaser-driven movement to a community-wide
collaboration, inviting the participation of purchasers, hospitals, health plans, physicians, unions,
consumer groups, and others. The goal of these Roll-Outs is to demonstrate that the Leapfrog
action plan can lead to a higher proportion of hospital admissions occurring at hospitals with the
appropriate Leapfrog safety practices in place.
At the same time as purchasers work together regionally to implement Leapfrog’s action plan
through designated Roll-Outs, Leapfrog purchasers in other parts of the country will work
individually and with others to begin implementing the Leapfrog initiative and work toward fullscale regional implementations in their particular part of the country.
Hospitals around the country are invited to complete the survey and share their performance with
their community, regardless of whether or not they are located in a Leapfrog-supported region.
The survey is available to all hospitals via the Web.
17. Who is rolling out the survey in which geographic regions?
The Leapfrog Group has thus far focused on forty-two “Regional Roll-Out” areas. The geographic
regions are defined, and periodically updated, on the ‘Get a Security Code’ page of the online
survey. The list of the purchaser or purchaser group leading the effort in each of the regions can
be found at: https://www.leapfroghospitalsurvey.org/code_request/contacts
18. Whom should I contact to discuss the rollout of this survey in my region or other regionspecific issues?
See the list of roll-out regions on the ‘Get a Security Code’ page of the online survey and use the
link to find the name and number of the local contact(s) for your region.
Leapfrog Hospital Recognition Program
19. What is the relationship between the Leapfrog Hospital Survey and the Leapfrog Hospital
Recognition Program (LHRP)?
The Leapfrog Hospital Recognition Program is a hospital pay-for-performance program which,
effective with the 2008 survey, relies solely on data collected through the Leapfrog Hospital
Survey. Additional data collection is no longer required to participate in the program. Since the
Leapfrog Hospital Survey is the now the sole data collection instrument, participation in the LHRP
is greatly simplified.
20. How does a hospital participate in the Leapfrog Hospital Recognition Program?
An employer or health plan must license the program from The Leapfrog Group and invite your
hospital to participate. The LHRP is currently being implemented in New Jersey by Horizon Blue
Cross Blue Shield of New Jersey; it is also being piloted by Aetna with certain hospitals in the
Seattle region. If your hospital is interested in participating in this program, we encourage you to
talk to employers and health plans in your market.
21. If my hospital participates in the LHRP, what data need to be submitted, and how do I
submit the data?
Hospitals participating in the LHRP must complete the Leapfrog Hospital Survey and submit their
data through Leapfrog’s secure survey web site TWICE during the annual survey cycle. The
Leapfrog Hospital Survey collects data that address overall hospital quality (e.g., Computerized
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Physician Order Entry, Intensivist Staffing, and Safe Practices) as well as quality within specific
clinical areas (e.g., Acute Myocardial Infarction, Pneumonia, and Coronary Artery Bypass Graft).
Efficiency data is also collected through the Leapfrog Hospital Survey. The survey collects all the
data required of LHRP-participating hospitals. If you are a LHRP-participating hospital, it is critical
that you complete the Leapfrog Hospital Survey by the requisite deadlines.
22. What is the data submission timeline for hospitals participating in the rewards program?
LHRP requires submission of a Leapfrog Hospital Survey twice during the annual survey cycle. A
current survey must be submitted by June 30th. An updated survey must be submitted between
November 1st and December 31st. For full LHRP details, please see:
http://www.leapfroggroup.org/for_hospitals/fh-incentives_and_rewards/hosp_rewards _prog.
Please note that to qualify for rewards from the health plan and/or employer implementing the
program in your region, your hospital must submit data by both deadlines.
23. Is it true that hospitals no longer need to use a Leapfrog-approved core measure vendor in
order to participate in the rewards program?
Yes. The revisions to the Leapfrog Hospital Survey and to the rewards program eliminate the
requirement for core measure data vendors to participate.
24. How do hospitals submit efficiency information without relying on their core measure
vendor?
In the past, participating in the LHRP required core measure vendors to report case-specific data
for the efficiency measures and for the models used to risk-adjust these measures. The process
has been simplified to enable hospitals to report the required data for the efficiency measures and
risk-adjustment models on their own through the survey. For certain clinical areas, hospitals will
now self-report aggregated patient data (case counts of discharges and associated risk factors),
which hospitals can obtain from easily accessed administrative data sources and do not require
chart abstraction. After this information is submitted through the survey, risk-adjustment
methodology will be applied by Leapfrog.
25. How do hospitals use their core measure data to report to the Leapfrog Hospital Survey?
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. Leapfrog will only need the total denominator and total numerator for the four
quarters of the given reporting period. Hospitals that do NOT participate in the Joint Commission
or CMS initiatives will still be able to report these process measures. Leapfrog publishes
specifications to allow hospitals to measure themselves.
26. Around which areas does the LHRP evaluate and reward hospitals?
The LHRP evaluates hospital performance across all of the quality and resource utilization
measures captured in the Leapfrog Hospital Survey. This includes general quality initiatives such
as CPOE and IPS, along with clinical areas such as CABG, PCI, AMI, and Pneumonia.
27. How are hospitals evaluated in the LHRP using the Leapfrog Hospital Survey measures?
The quality and resource utilization measures are weighted and rolled up into an overall efficiency
score which is used to determine recognition and rewards levels. The quality measures account
for 65% of the overall efficiency score and the resource utilization measures account for 35% of
the overall efficiency score. More scoring details on the LHRP can be found at:
http://www.leapfroggroup.org/media/file/LHRP-Hosp_Scoring_System.pdf
28. Does the LHRP reward top performing hospitals, hospitals which show improvement, or
both?
A hospital’s overall efficiency score, a weighted combination of quality and resource utilization
measures, determines its performance category—Attainment or Improvement. These
performance categories contain different recognition and rewards types as determined by the
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local payer, typically in collaboration with participating hospitals. Below are the typical rewards
options that payers offer in the LHRP:
Attainment Category

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Contract rate adjustment
Patient shift
Public recognition
Pre-set dollar amount
Improvement Category

Pre-set dollar amount

Shared savings dollar amount

Contract rate adjustment
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Section 2: CPOE
Section 2: 2011 Computerized Physician Order Entry (CPOE) Leap
What’s New in the 2011 Survey
1.
An updated version of the CPOE Evaluation Tool has been introduced. Version 2.0 of the CPOE
Evaluation Tool includes both new simulated patients and problem orders. The updates included
in v2.0 address many of the comments hospitals have provided to Leapfrog and the Tool
developers over the last two years.
Change Summary since Release
None. If substantive changes are made to this section of the survey after release on April 1, they will be
documented in this Change Summary section.
CPOE Frequently Asked Questions (FAQs)
1. What is the definition of “functioning” CPOE?
Functioning means only that a CPOE system (real-time intercept of potentially problematic
physician orders) is currently operational in any inpatient unit in the hospital. It does not imply that
the Leapfrog standards are fully met.
2. Is there a common vision of how CPOE should look (e.g., GUI interface, connectivity to
hand-held devices, etc.)?
No. The Leapfrog Group is interested in promoting the use of CPOE systems that are effective at
preventing serious medication errors, but does not specify a comprehensive set of specifications.
The Leapfrog Group uses in the survey a CPOE evaluation methodology developed by First
Consulting Group and the Institute for Safe Medication Practices, with ongoing updates funded by
the Agency for Healthcare Research and Quality (AHRQ); it provides hospitals with a tool to test
the effectiveness of their CPOE system implementation.
3. How do hospitals access the CPOE Evaluation Tool?
Hospitals completing the survey and indicating in Section 2, question 1, that they have a
functioning CPOE system in at least one inpatient unit of the hospital will be eligible to access the
CPOE Evaluation Tool. After they complete the CPOE section of the survey and submit the
survey, they should go to the home page of the online survey site to access the CPOE Evaluation
Tool. When they complete the evaluation, their survey results will be adjusted by Leapfrog to
reflect their performance on the tool. Once the evaluation is complete, hospitals will need to come
back into the survey and complete any uncompleted sections of the survey, or they will receive a
score of “Declined to Respond” for those sections.
4. Does a pharmacy system that catches prescribing errors like potential interactions, dosing
errors, etc. qualify as a CPOE? I.e. (a) physician dictates or writes order;(b) nurse or unit
clerk may transcribe order but then sends order to pharmacy; (c) order entered into
pharmacy system after received in the pharmacy; (d) system alerts someone in pharmacy
if potential problem and pharmacy calls prescriber?
No. This does not qualify as CPOE. In fact, the very large favorable impact documented at the
Brigham and Women’s hospital was achieved when CPOE replaced a prior electronic prescribing
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Section 2: CPOE
system identical to the pharmacy order entry systems which the inquirer is describing. While it is
very important to eliminate hand-written prescriptions, it is also important to have in place
decision-support.
5. What level of feedback will the CPOE Evaluation Tool provide our hospital about our CPOE
system?
Hospitals that complete the CPOE Evaluation Tool will be provided with feedback on those
scenarios that include a potentially fatal order that their CPOE system did not correctly alert the
prescriber. Due to the costs associated with developing the patients and orders for the tool, the
database of orders and patients is limited. Therefore, revealing all of the incorrect or missed
alerts would provide hospitals that have taken the tool before a potential advantage over hospitals
with recent CPOE implementations.
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CPOE Scoring Algorithm
Score on CPOE Evaluation Tool
Fully
Implemented
Good
Progress in
Implementing
Good Early
Stage Effort
Completed
The
Evaluation
Incomplete
Evaluation
(Failed deception
analysis)
-orDid not
complete an
evaluation
Fully Meets
Standards
Fully Meets
Standards
Substantial
Progress
Substantial
Progress
Willing to Report
50-74% of all inpatient
medication orders
entered through
CPOE System
Substantial
Progress
Substantial
Progress
Substantial
Progress
Some
Progress
Willing to Report
25-49% of all inpatient
medication orders
entered through
CPOE System
Substantial
Progress
Some
Progress
Some
Progress
Some
Progress
Willing to Report
Some Progress
Some
Progress
Willing to
Report
Willing to
Report
Willing to Report
Implementation
Status
75% or greater of all
inpatient medication
orders entered
through CPOE
System
CPOE implemented at
least one inpatient unit
but <25% of all
inpatient medication
orders entered
through CPOE
System
CPOE not
implemented in at
least one inpatient unit
Can not take CPOE Evaluation Tool; Will receive score of “Willing to Report”
Declined to respond:
The hospital did not respond to this section of the survey, or the hospital was asked to complete the
survey but has not submitted one.
Response not required:
Hospital not targeted for reporting on this Leap.
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Section 3: EBHR
Section 3: 2011 Evidence-Based Hospital Referral (EBHR) Leap
What’s New in the 2011 Survey
In the EBHR section 3, the following changes have been made:
1. The current three process measures for percutaneous coronary interventions (PCI) have been
replaced with a single process measure – median door-to-balloon time (CMS/Joint Commission
measure AMI-8). A hospital will need to report a median time of 60 minutes or less to receive
credit for having good processes of care.
2. Leapfrog has shifted its preference for cardiac surgery outcome reporting from state reports to
national performance measurement systems, when available. Leapfrog’s preference for the 2011
survey will be for hospitals to report their risk-adjusted mortality rates from national registry data –
either the Society of Thoracic Surgeons (STS) or the American College of Cardiology’s National
Cardiovascular Data Registry (NCDR CathPCI). For hospitals that do not participate in STS
and/or NCDR, they will be able to continue reporting their data from an approved state report or a
regional registry (Northern New England Cardiovascular Disease Study Group or Blue Cross Blue
Shield of Michigan Cardiovascular Consortium). For hospitals that do not participate in any
performance measurement reporting initiative, or do not want to share their results from the latest
report, Leapfrog will continue calculating a Survival Predictor for the hospital’s outcome metric.
Change Summary since Release
None. If substantive changes are made to this section of the survey after release on April 1, they will be
documented in this Change Summary section.
December 13, 2011


Updated the reporting instructions for actual and expected mortality rates from the NCDR CathPCI
registry.
Updated the exclusion criteria for CABG volume question #20, to include MDC 14 (pregnancy,
childbirth, and puerperium) as an exclusion code.
June 8, 2011
Clarified the ICD-9-CM diagnosis codes that should be used for counting patients with a risk factor (CABG
and PCI).
April 29, 2011
Updated the page numbers in the STS report for which hospitals should use to report CABG and AVR
outcomes.
May 6, 2011
Updated the links to the Massachusetts state outcome reports for CABG and PCI to the FY2009 report.
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EBHR Reporting Time Periods
When completing survey section 3, use this as a guide to the time periods for which data are to be
collected and/or reported.
Procedure/ Condition
Surveys submitted prior to
November 1, 2011
Surveys submitted on or after
November 1, 2011
12 months ending
December 31, 2010
12 months ending
June 30, 2011
CABG
Volume
National Performance
Measurement (STS)
Most recent 12-month report received from STS
(indicate month-year ending of period in Q5)
Publicly Reported
Outcomes
(CA, MA, NJ, NY, and
PA only)
Most recently available public results.
Follow instructions on pp. 26-29 of this document.
(indicate month-year ending of period in Q9)
Regional Registry
(NNECDSG)
Most recent 12-month report received from NNECDSG
(indicate month-year ending of period in Q9)
Process Measures of
Quality
12 months ending
December 31, 2010
12 months ending
June 30, 2011
Hospitals reporting based on
data submitted to Joint
Commission, CMS, or STS:
1Q10–4Q10 when available
or
the most recent 12-month period available,
ending not more than 12 months ago
3Q10–2Q11, when available
or
the most recent 12-month period available,
ending not more than 12 months ago
Resource Utilization
Measures
12 months ending
December 31, 2010
12 months ending
June 30, 2011
Volume
12 months ending
December 31, 2010
12 months ending
June 30, 2011
PCI
National Performance
Measurement (NCDR
CathPCI Registry)
Publicly Reported
Outcomes
(MA and NY only)
Regional Registries
(NNECDSG/BMC2)
Process Measures of
Quality
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Most recent 12-month report received from NCDR CathPCI Registry
(indicate month-year ending of period in Q5)
Most recently available public results
Follow instructions on pp. 52-54 of this document.
(indicate month-year ending of period in Q9)
Most recent 12-month report received from NNECDSG/BMC2
(indicate month-year ending of period in Q9)
12 months ending
December 31, 2010
12 months ending
June 30, 2011
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Procedure/ Condition
Hospitals reporting based on
data submitted to Joint
Commission or CMS:
Resource Utilization
Measures
Section 3: EBHR
Surveys submitted prior to
November 1, 2011
Surveys submitted on or after
November 1, 2011
1Q10–4Q10, when available
or
the most recent 12-month period available,
ending not more than 12 months ago
3Q10–2Q11, when available
or
the most recent 12-month period available,
ending not more than 12 months ago
12 months ending
December 31, 2010
12 months ending
June 30, 2011
12 months, or 24 months
(annual average), ending
December 31, 2010
12 months, or 24 months
(annual average), ending
June 30, 2011
AVR
Volume
National Performance
Measurement (STS)
Regional Registry
(NNECDSG)
Most recent 12-month report received from STS
(indicate month-year ending of period in Q4)
Most recent 12-month report received from NNECDSG
(indicate month-year ending of period in Q8)
AAA
Volume
12 months, or 24 months
(annual average), ending
December 31, 2010
12 months, or 24 months
(annual average), ending
June 30, 2011
12 months or 24 months ending
December 31, 2010
12 months or 24 months ending
June 30, 2011
12 months, or 24 months
(annual average), ending
December 31, 2010
12 months, or 24 months
(annual average), ending
June 30, 2011
12 months, or 24 months
(annual average), ending
December 31, 2010
12 months, or 24 months
(annual average), ending
June 30, 2011
12 months, or 24 months
(annual average), ending
December 31, 2010
12 months, or 24 months
(annual average), ending
June 30, 2011
Volume
12 months ending
December 31, 2010
12 months ending
June 30, 2011
Process Measures of
Quality
12 months ending
December 31, 2010
12 months ending
June 30, 2011
… most recent 12-month VON report
… most recent 12-month VON report
Process Measure of
Quality
Pancreatic Resection
Volume
Esophagectomy
Volume
Bariatric Surgery
Volume
High-Risk Deliveries
Participating hospitals may use
data from latest VON report for:
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EBHR General Information
EBHR Frequently Asked Questions (FAQs)
General Questions
1. How are the procedure codes used to define the high-risk procedures; do they refer to
primary procedure codes, or primary or secondary codes?
When counting patient volume for the procedure, the procedure code may be in either a primary
or secondary field. The High Risk Delivery volume measure also utilizes diagnosis codes to
determine volume of very low birth weight babies. The diagnosis can be either primary or
secondary for determining the elective status of the high risk delivery.
For the Leapfrog Expert-Panel/NQF Endorsed Process Measures of Quality, see the
specifications for each of those indicators; many require that the procedure code be the primary
or principal procedure, e.g., isolated CABG. Don’t use the Process Measures specifications for
counting volume, and vice versa.
2. What criteria were used to identify the codes? Sometimes it appears that an entire code
group was selected and at other times just a subset of a code group was selected?
Codes were determined by the measure developer; Leapfrog is using endorsed or national
performance measures in the survey where possible. Thus, we use the codes identified by the
specific measure developer.
All exclusions are intentional. They are based on a combination of the actual mortality risk of the
condition, clinical judgment, and consistency with data and measure sources in the evidence
used to establish volume cutpoints. Additionally, codes may be retired and new codes added by
the coding developers.
3. We are developing a volume report for our hospital. Our counts include all coded
procedures that match the ICD-9 codes for each of the seven high-risk surgeries of the
Leapfrog EBHR standard. The volume numbers in our report are higher than the number of
discharges. Should we count procedures or discharges?
Count discharges that have one or more of the procedure codes for that respective high-risk
surgery. A patient discharge should never be counted more than once for the high-risk procedure.
(The same patient discharge may be counted once each for different high-risk surgeries if the
patient stay included different high-risk procedures, e.g., a PCI followed by a CABG during the
same stay.)
4. Why is Leapfrog asking for the number of deaths in our hospital for specific procedures?
How will this information be used?
The Leapfrog Group collects this information for use in a composite measure of survival
developed by experts in the measurement of quality and safety. This measure utilizes information
on hospital volume and mortality. More information about the composite surgical survival
measure is available on the Survey homepage. Leapfrog does not publish the specific number of
deaths occurring for the procedure; it instead publishes the results of the composite measure.
5. How we should we count the following procedures?
a. When stents are done in conjunction with PTCAs, does this count as one or two?
This should count as one since both procedures were done during the same patient stay.
b. When a patient has a procedure done multiple times during an admission?
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Count the patient only once for that high-risk procedure. If the procedure is repeated during a
subsequent hospital stay, count that one as well.
6. My hospital is in one of the public outcomes reporting states but the latest mortality
outcomes are not included in this document. Why not? Should I use the more recent
results to respond?
If there has been a recent update to your statewide CABG (CA, MA, NJ, NY, or PA) or PCI (MA
or NY) mortality outcomes, please contact the Help Desk which will update this document to
reflect the new results.
7.
Where can I find more information about the STS, NNECDSG, BMC2, NCDR CathPCI
Registry, and ACS measurement systems for CABG, PCI, AVR and Bariatric Surgery,
respectively? How do I determine whether our hospital has participated in any of those
measurement systems and what our performance has been?
Follow the links for STS (www.sts.org), NNECDSG (www.nnecdsg.org), BMC2 (www.bmc2.org)
NCDR CathPCI Registry (https://www.ncdr.com/webncdr/DefaultCathPCI.aspx), and ACS
(www.acsnsqip.org; or www.facs.org) at the beginning of the EBHR survey section for more
information about these measurement systems. Your hospital’s participation status or
performance results are not publicly reported on any of the sites and Leapfrog does not have
access to that information. Your hospital’s chief of thoracic surgery and chief of cardiology or
general surgery may know more about these measurement systems, and they should know
whether your hospital has recently participated in them and, if so, the results for your hospital.
8. How will The Leapfrog Group account for hospitals that do not perform all of the high-risk
surgeries?
A hospital’s responses are evaluated separately by high-risk procedure or condition. For a
hospital not performing a high-risk procedure on an elective basis, or does not admit high-risk
deliveries, the standard for that procedure or condition does not apply and this will be indicated in
Leapfrog public results.
Process Measures
1. Why has Leapfrog changed its measures from previous years?
The Leapfrog Group continues to harmonize its process measures with measures from other
national measurement groups as available.
Questions re: Measuring Adherence for Indicators NOT Reported Nationally
2. I have fewer than 60 cases? Should I measure and report adherence for the indicator(s)?
Yes. Use all the cases that meet the criteria.
3. What is the method that should be used to draw the sample of 60 cases?
Hospitals will need to pull a random sample of more than 60 cases, since some cases will be
eliminated based on the exclusion criteria. The exclusion criteria differ from indicator to indicator,
so you’ll need additional cases for that reason as well. Start by pulling a random sample of cases
in excess of 60. If you need additional cases to make 60 because of the exclusion criteria, just do
another random sample from remaining cases not already sampled. Hospitals with fewer than 60
cases in total for any procedure should review all cases.
To sample cases randomly, use a technique that ensures that individual eligible cases in a
population for the entire time period have an equal chance of being selected. Consider using
methods similar to those described by the Joint Commission for its National Hospital Quality
Measures.
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Section 3: EBHR
4. Does this mean that each indicator within the clinical groups will have its own sample of
60?
All will start with a sample size of 60, if at least 60 patients were hospitalized with that condition.
Additional patients may be required depending on the number of patients who meet the inclusion
and exclusion criteria per indicator.
5. Does this mean that all cases will need to be screened for contraindications and then a
random sample is selected from the remaining records? (Ex. 131 mothers with deliveries
at 24-34 weeks, all charts are reviewed and patients with contraindications to steroids are
eliminated. A random sample of 60 is then selected from the remaining cases.)
60 consecutive cases are to be selected, if at least 60 patients were hospitalized with that
condition. Because some of these patients might not meet the exclusionary criteria for each
indicator, additional patients may be required to end with 60 patients per indicator who satisfy the
inclusionary and exclusionary criteria. If 60 patients who meet the inclusionary and exclusionary
criteria cannot be identified, use the total number of eligible patients during that calendar year.
6. Do the inclusion/exclusion criteria apply to both numerator and denominator?
Yes. In fact, for each indicator, you should apply all inclusion/criteria to establish cases in the
denominator first, either all cases meeting those criteria or a sample of 60 if more than 60 meet
all the criteria. The numerator is simply those cases from the denominator that meet the clinical
guideline, and the numerator never includes cases not in the denominator.
7. Many of the measures exclude cases where a therapeutic agent/drug is contraindicated.
Does the physician need to document the reason or specific contraindication in the
medical record, or is it sufficient that the medical record simply indicate “discontinue” or
“contraindicated”.
The specific reason or contraindication must be documented in the medical record by the
prescriber.
EBHR Scoring Algorithm
Quality Score (General)
For hospitals that report risk-adjusted outcomes for a surgical procedure from a national measurement
system, from an approved statewide report (CA-CABG, MA-CABG, MA-PCI, NJ-CABG, NY-CABG, NYPCI, PA-CABG), or from a regional registry, their quality score for that surgical procedure is based on a
combination of overall hospital volume, risk-adjusted mortality rates, and adherence to process of care
measures for the procedure.
For hospitals that do not report a risk-adjusted outcome for a surgical procedure from a national
performance measurement system, from an approved statewide report, or from a regional registry, their
quality score for that surgical procedure is based on their Survival Predictor performance and adherence
to process of care measures for the procedure. See below for details on the Survival Predictor
calculation and scoring.
A hospital's EBHR quality score for a procedure is based on the sum of partial credits. The total credits
are reflected in an overall result for each surgical procedure, which Leapfrog displays in its public release
of survey results as filled bars:
 Fully meets standards: Full credit -- 4 filled bars
 Substantial progress: ¾ credit -- 3 filled bars
 Some progress: ½ credit -- 2 filled bars
 Willing to report: ¼ credit -- 1 filled bar
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Declined to respond means:
The hospital did not respond to this section of the survey, or the hospital was asked to complete the
survey but has not submitted one.
N/A -- Standard does not apply means the hospital does not perform this procedure on an elective
basis. (answered No to #1 - #7 for the corresponding procedure).
Quality Score (Survival Predictor)
A Survival Predictor will be calculated for each high-risk surgery, except Bariatric surgery, that a hospital
performs electively, and does not report a risk-adjusted outcome.
The Survival Predictor is a composite measure that predicts future mortality rates and can be calculated
for six of the EBHR high-risk surgeries. The measures are designed to optimally forecast hospital
performance, based on prior hospital volumes and prior mortality rates. More details on the Survival
Predictor composite measure can be found in a white paper on the Survey homepage:
http://www.leapfroggroup.org/media/file/SurvivalPredictorWhitepaper.pdf.
Also see more details about calculating and scoring the Survival Predictor at
http://www.leapfroggroup.org/media/file/2011SurveySurvivalPredScoring.pdf
The composite measure is a weighted combination of a hospital’s observed raw mortality rate and the
mortality rate expected given the hospital’s volume. The observed mortality rate is weighted according to
reliability (a function of the case volume at that hospital). The composite measure is found to be a good
predictor of subsequent hospital performance.
A hospital’s result on the composite measure will determine their performance category for that
procedure:
 Best Odds of Survival means the hospital is in the best quartile for the composite measure for
that procedure.
 Better Odds of Survival means the hospital is above the midpoint (median), but not in the best
quartile for the composite measure for that procedure.
 Improved Odds of Survival means the hospital is below the midpoint (median), but not in the
worst quartile for the composite measure for that procedure.
 Lower Odds of Survival means the hospital is in the worst quartile for the composite measure
for that procedure.
 Declined to respond means the hospital did not respond to this section of the survey, or the
hospital was asked to complete the survey but has not submitted one.
 Does Not Apply means the hospital does not perform the procedure electively.
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Section 3: EBHR
CABG Measure References
CABG Volume: Survey
p.16
For CABG, there are two sets of ICD-9-CM codes for counting patients for each of these procedures. The
first set of codes is for counting all patients who have had the procedure (Question #1). The second set
of codes for CABG is for counting patients who have had an isolated procedure (CABG Question #2).
While it is expected that most procedures would be indicated as a principal procedure given their severity,
if the procedure code is found in a secondary position, the patient can be counted if the code qualifies
according to the definition.
Do not use these codes for measuring and reporting the Nationally-Endorsed Procedure-Specific
Process Measures of Quality; use the separate specifications for those indicators. Patient
populations used for the Process Measures typically DIFFER from patient populations included
here in the volume counts.
Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volumes,
count the number of patients with any one or more of the specified procedure codes for that EBHR
procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all
procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether
the patient qualifies to be counted.
The count for the volume measures can include emergent cases as well as “elective” scheduled cases.
Q.1: All patients undergoing procedure
Source: (AHRQ IQI 5) Version 4.2 Agency for Healthcare Research and Quality
Number of patients discharged, age 18 years and older, with ICD-9-CM procedure codes of 36.10-36.17,
or 36.19 in any procedure field.
ICD-9-CM
36.10
36.11
36.12
36.13
36.14
36.15
36.16
36.17
36.19
CABG procedure codes:
Aortocoronary bypass for heart revascularization, not otherwise specified
Aortocoronary bypass for one coronary artery
Aortocoronary bypass for two coronary artery
Aortocoronary bypass for three coronary artery
Aortocoronary bypass for four or more coronary arteries
Single internal mammary –coronary artery bypass
Double internal mammary –coronary artery bypass
Abdominal-coronary artery bypass
Other bypass anastomosis for heart revascularization
Exclude cases:
 MDC 14 (pregnancy, childbirth, and puerperium)
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Section 3: EBHR
Q.2: Patients with an isolated CABG procedure
Source: CMS
Number of patients identified in Question #1 without a concomitant valve replacement and without an
organ transplant. Exclude all cases in Question #1 with an ICD-9-CM procedure code of 35.10-35.29 in
any procedure field and all cases who received an organ transplant during the inpatient hospital stay.
ICD-9-CM
35.10
35.11
35.12
35.13
35.14
35.20
35.21
35.22
35.23
35.24
35.25
35.26
35.27
35.28
procedure codes for valve replacement or repair:
Open heart valvuloplasty without replacement, unspecified valve
Open heart valvuloplasty of aortic valve without replacement
Open heart valvuloplasty of mitral valve without replacement
Open heart valvuloplasty of pulmonary valve without replacement
Open heart valvuloplasty of tricuspid valve without replacement
Replacement of unspecified heart valve
Replacement of aortic valve with tissue graft
Other replacement of mitral valve with tissue graft
Replacement of mitral valve with tissue graft
Other replacement of mitral valve
Replacement of pulmonary valve with tissue graft
Other replacement of pulmonary valve
Replacement of tricuspid valve with tissue graft
Other replacement of tricuspid valve
ICD-9-CM
50.51
50.59
52.80
52.82
52.83
55.61
55.69
33.50
33.51
33.52
procedure codes for major organ transplant:
Auxiliary liver transplant
Other transplant of liver
Pancreatic transplant, not otherwise specified
Homotransplant of pancreas
Heterotransplant of pancreas
Renal autotransplantation
Other kidney transplantation
Lung transplant, not otherwise specified
Unilateral lung transplant
Bilateral lung transplant
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CABG Outcomes Specifications: Survey
Section 3: EBHR
p.16
Q. 4 - 7: Instructions for National Registry Reporting
Entity:
Observed
mortality rate:
STS (Also applied to AVR)
For the latest year reported, enter your hospital’s “Operative Mortality, Risk-adjusted
rate” for CABG (report p. CAB-29 or a page nearby) or for AVR (report p. AV
Replace-61 or a page nearby) 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 postoperative mortality out-of-hospital.
Expected
mortality rate:
Enter the all-hospital STS “Operative Mortality, Risk-adjusted rate” for CABG (report
p. CAB-29 or a page nearby) or AVR operative mortality (report p. AV Replace-61 or
a page nearby) in CABG Q7 and AVR Q6, respectively. These are the national
expected operative mortality rates to which you 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.
Q. 8 - 12: Instructions for State and Regional Registry Reporting
General State Instructions (For hospitals in CA, MA, NJ, NY and PA only)








For hospitals located in a state with a public release of risk-adjusted mortality outcomes, use the
information below to determine responses to CABG questions 8 – 12. Use the public report for the
time period indicated below when responding.
Follow the links below to the appropriate public report.
Do not substitute data from reports other than those cited here when responding.
If you are aware of a newer public release of risk-adjusted mortality outcomes in your state, please
contact the Leapfrog Help Desk (https://www.leapfroghospitalsurvey.org/helpdesk) as soon as
possible.
Question 8 – included in public report: Determine from the public data sources cited below whether
risk-adjusted mortality outcomes were publicly reported for your hospital in the latest public data
available in your state for the time period indicated. If your hospital’s results are not included in that
source, respond “no” to this question and skip questions 9 – 12.
Question 9 – public report time period: Indicate in the survey response the 12-month reporting
period ending, as indicated below.
Question 10 – different hospital name (optional): If the public report linked below indicates a hospital
name different from the hospital name entered in the survey’s Organization Information (section 1),
indicate the hospital’s name as it appears in the public report.
Questions 11 and 12 – hospital mortality rates: For each respective procedure and the state where
the hospital is located, follow the additional instructions below for reporting observed mortality rate
and expected mortality rate in survey questions 11 and 12, respectively, for the applicable EBHR
surgical procedure.
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State Specific Instructions
State:
Source:
CA
http://www.oshpd.ca.gov/HID/Products/PatDischargeData/CABG/2007/HospitalResults.pdf
(Table 3)
Q8:
If your hospital is not listed, answer ‘No’, and skip Q9 – Q12; else enter ‘Yes’ and continue.
Q9:
Report 12-month Time Period ending = 122007
Q10:
Indicate hospital’s name as presented in public report, if different from hospital name indicated
in Q1 of survey section 1.
Q11:
Report Observed Mortality Rate (%), as a percent with two decimal-place precision.
Q12:
Report Expected Mortality Rate (%) as a percent with two decimal-place precision.
More
http://www.oshpd.ca.gov/HID/Products/PatDischargeData/CABG/
Info:
IMPORTANT: Disregard Risk-Adjusted Mortality Rate in the public report when responding to Q11 & Q12.
State:
Source:
MA
http://www.massdac.org/sites/default/files/reports/CABG%20FY2009.pdf (Figure 7.1)
Q8:
If your hospital is not listed, answer ‘No’, and skip Q9 – Q12; else enter ‘Yes’ and continue.
Q9:
Report 12-month Time Period ending = 092009
Q10:
Indicate hospital’s name as presented in public report, if different from hospital name indicated
in Q1 of survey section 1.
Q11:
Report SMIR (%) indicated on right side of graph (Figure 7.1) as a percent with two decimalplace precision for the observed mortality rate.
Q12:
All hospitals must report 1.19% -- the statewide Unadjusted Mortality Rate from the graph
(Figure 7.1) -- as a percent with two decimal-place precision for the expected mortality rate.
This is the expected rate to which the SMIR% is comparable.1
IMPORTANT: Do not report the Expected Mortality% from Figure 7.1.
Absent an observed mortality rate, that is a measure of severity, not hospital performance.
More
Info:
http://www.massdac.org/reports/surgery.html
The Commonwealth public report does not include hospitals’ observed mortality rates. The SMIR(%) is each
hospital’s actual (observed) mortality rate, standardized (risk-adjusted) to the average case severity for all reporting
hospitals included in the report. Since the statewide un-adjusted rate reflects the same average case severity, that
“Unadjusted Mortality Rate“ must be used as the expected rate and SMIR% as the observed.
Note that O/E ratio, Observed / Expected, is equal to SMIR / Unadjusted (statewide) Mortality Rate in this case.
1
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Section 3: EBHR
State:
Source:
NJ
http://www.nj.gov/health/healthcarequality/documents/cardconsumer07.pdf
(Table D2, p. 26)
Q8:
If your hospital is not listed, answer ‘No’, and skip Q9 – Q12; else enter ‘Yes’ and continue.
Q9:
Report 12-month Time Period ending = 122007
Q10:
Indicate hospital’s name as presented in public report, if different from hospital name indicated
in Q1 of survey section 1.
Q11:
Report Observed Patient Mortality (%) as a percent with two decimal-place precision.
Q12:
Report Expected Patient Mortality (%) as a percent with two decimal-place precision.
More
http://www.state.nj.us/health/healthcarequality/cardiacsurgery.shtml
Info:
IMPORTANT: Disregard Risk-Adjusted Patient Mortality in the public report when responding to Q11 &
Q12.
State:
Source:
NY
http://www.health.state.ny.us/statistics/diseases/cardiovascular/heart_disease/docs/20062008_adult_cardiac_surgery.pdf (Table 2, p.16)
Q8:
If your hospital is not listed, answer ‘No’, and skip Q9 – Q12; else enter ‘Yes’ and continue.
Q9:
Report 12-month Time Period ending = 122008
Q10:
Indicate hospital’s name as presented in public report, if different from hospital name indicated
in Q1 of survey section 1.
Q11:
Report OMR – Observed Mortality Rate % – as indicated, maintaining two decimal-place
precision.
Q12:
Report EMR – Expected Mortality Rate % – as indicated, maintaining two decimal-place
precision.
More
http://www.health.state.ny.us/statistics/diseases/cardiovascular/
Info:
IMPORTANT: Disregard RAMR (Risk-Adjusted Mortality Rate) in the public report when responding to
Q11 & Q12.
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State:
Source:
Section 3: EBHR
PA
http://www.leapfroggroup.org/media/file/2011SurveyPA2008cabg.pdf (PDF version)
http://www.leapfroggroup.org/media/file/2011SurveyPA2008cabg.xls (Excel version)
These documents were abridged from original data at the public site:
http://www.phc4.org/reports/cabg/08/data/cabg2008hospdata.xls
Only data for “Reporting Group=CABG without Valve” were retained in the abridged editions.
Note:
Use only results for isolated CABGs at your hospital, i.e., where Reporting Group (column B)
indicates “CABG without Valve”
Q8:
If your hospital is not listed, answer ‘No’, and skip Q9 – Q12; else enter ‘Yes’ and continue.
Q9:
Report 12-month Time Period ending = 122008
Q10:
Indicate hospital’s name as presented in public report, if different from hospital name indicated
in Q1 of survey section 1.
Q11:
Report Actual In-Hospital Mortality Rate (%) , spreadsheet column E, as a percent with two
decimal-place precision for the observed mortality rate..
Q12:
Report Expected In-Hospital Mortality Rate (%) , spreadsheet column G, as a percent with
two decimal-place precision for the expected mortality rate.
More
http://www.phc4.org/reports/cabg/
Info:
IMPORTANT: Disregard RAMR (Risk-Adjusted Mortality Rate) in the public report when responding to
Q11 & Q12.
Instructions for Regional Registries
Entity:
Observed
mortality rate:
Expected
mortality rate:
December 13, 2011
v5.3.4
NNECDSG (Also Applied to PCI and AVR)
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.
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CABG Process Measure Specifications: Survey
Section 3: EBHR
p.18
The specifications are for auditing and measuring the rate of adherence to the process measures of
quality included in the Leapfrog Hospital Survey.
Because of the clinical specificity needed, procedure and condition definitions DIFFER from those
used to count volume of procedures elsewhere in the survey and process measure denominator
counts should not be used for that purpose.
NATIONAL PERFORMANCE MEASUREMENT SYSTEMS
To reduce the reporting burden on survey respondents, every effort has been made to harmonize these
process measures with national performance measurement systems endorsed and sponsored by the
following organizations:
 The Joint Commission (TJC),
 Centers for Medicaid and Medicare Services (CMS),
 Society for Thoracic Surgeons (STS).
Most are National Quality Forum (NQF) Endorsed Measure Sets.
Links throughout this document to The Joint Commission Appendices and Table definitions can be
located at:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures/
GENERAL INSTRUCTIONS
The specifications in this document for each of the process measures indicate whether the measure
coincides with one that your hospital may already have measured and reported to one of these national
performance measurement systems.
1. For any process measure in the Leapfrog survey that coincides with a measure specified in a
national performance measurement system, if your hospital has
 measured adherence to that process-of-care quality indicator, and
 reported the results to The Joint Commission, CMS, or STS. . .
 for the Reporting Time Period of that measure as indicated in the survey,
then . . .
Use data and results as reported to that organization for that measure for the Reporting Time
Period specified in the survey.
In this case, to the extent any specifications below differ from the specifications for reporting the data
to those organizations, rely on the specifications of that organization.
2. Otherwise, you should measure adherence to the process-of-care quality indicator using the
specifications here and use those results in responding to the survey. See also the Frequently Asked
Questions at the end related to measuring these indicators.
In either case #1 or #2, we ask that you report the number of cases in the denominator and the number of
cases where there was adherence to the measurement standard (numerator).
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Section 3: EBHR
In order to attain credit for EBHR Quality, your hospital will need to have 80% or more adherence to a
minimum of four of the seven process measures.
CABG-1: Anti-platelet medication at discharge
Source: STS Measure 13
NQF Endorsed National Voluntary Consensus Standards for Cardiac Surgery
If you measured adherence to this process-of-care quality indicator and reported the results to STS for
the 12-month Reporting Time Period indicated in the survey, then use those data and results when
responding to the survey, and ignore the specifications here for this measure.
Otherwise, use these specifications to measure and report results for this measure.
Numerator: Number of patients who were discharged on aspirin/safety-coated aspirin or clopidogrel
after isolated CABG.
Denominator: All patients who had undergone an isolated CABG procedure (ICD-9-CM procedure
codes 36.10-36.19):
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.14
Aortocoronary bypass of four or more coronary arteries
36.15
Single internal mammary-coronary bypass
36.16
Double internal mammary-coronary bypass
36.17
Abdominal-coronary artery bypass
36.19
Other bypass anastamosis for heart revascularization
Note: This measure was designed to measure only isolated CABG; do not include in the numerator or
denominator any cases that had both a CABG and another cardiac surgery.
Exclusions:
 Patient < 20 years of age
 Transferred to another acute care hospital
 Expired during hospitalization
 Left against medical advice
 Discharge to hospice
 Contraindications to aspirin (as per The Joint Commission for aspirin in AMI) = Documentation of
one or more of the following: [NOTE: Patients having one or more of the following contraindications
may still potentially be eligible to receive other anti-platelet medication, e.g., clopidogrel.]
 Allergy to aspirin
 Active bleeding on admission or during hospitalization
 Warfarin prescribed upon discharge
 Other reasons as documented by physician, nurse practitioner, or physician assistant
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CABG-2: Isolated CABG using internal mammary artery
Source: CMS Measure 11
NQF Endorsed National Voluntary Consensus Standards for Hospital Care
If you measured adherence to this process-of-care quality indicator and reported the results to CMS for
the 12-month Reporting Time Period indicated in the survey, then use those data and results when
responding to the survey, and ignore the specifications here for this measure.
Otherwise, use these specifications to measure and report results for this measure.
Numerator: Number of patients who received an IMA graft (ICD-9 procedure codes 36.15 and 36.16)
Denominator: Number of surgical patients undergoing isolated CABG (ICD-9-CM procedure codes
36.10-36.19) who were discharged, transferred, or expired:
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.14
Aortocoronary bypass of four or more coronary arteries
36.15
Single internal mammary-coronary bypass
36.16
Double internal mammary-coronary bypass
36.17
Abdominal-coronary artery bypass
36.19
Other bypass anastamosis for heart revascularization
Exclusions:
Other heart procedures (ICD-9 procedure codes):
35.0-35.99
Valve related procedures; repair of septal defects
36.2
Heart revascularization by arterial implant
37.32
Excision of aneurysm of heart
37.34
Excision or destruction of lesion or tissue of heart, other approach
37.35
Partial ventriculectomy



Repeat CABG (ICD-9 status code V45.81)
Documentation of one or more of the following:
 The Left Anterior Descending (LAD) artery is not suitable for LIMA grafting (eg, donor or
target vessels <1.5 mm in size)
 Calcified or diffuse coronary disease in the LAD
 Subclavian stenosis
 Previous thoracic surgery
 Previous radiation
 Current use of immunosuppressive agents (eg, Prednisone, Imuran, or other)
 Coagulation disorder
 Myocardial infarction within 7 days prior to the procedure
 Chronic renal insufficiency
 Require emergent operation
 Require concomitant surgery (eg. aneurysm resection, valve replacement)
 Morbid obesity
Other reasons as documented by physician, nurse practitioner, or physician assistant
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CABG-3: Beta-blockers within 24 hours prior to isolated CABG surgery
Source: STS Measure 5
NQF Endorsed National Voluntary Consensus Standards for Cardiac Care
If you measured adherence to this process-of-care quality indicator and reported the results to STS for
the 12-month Reporting Time Period indicated in the survey, then use those data and results when
responding to the survey, and ignore the specifications here for this measure.
Otherwise, use these specifications to measure and report results for this measure.
Numerator: Number of patients coming to isolated CABG with documented pre-operative (24 hours)
beta blockade
Denominator: Total number of surgical patients with isolated CABG (ICD-9 procedure codes
36.10-36.19):
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.14
Aortocoronary bypass of four or more coronary arteries
36.15
Single internal mammary-coronary bypass
36.16
Double internal mammary-coronary bypass
36.17
Abdominal-coronary artery bypass
36.19
Other bypass anastamosis for heart revascularization
Note: This measure was designed to measure only isolated CABG; do not include in the numerator or
denominator any cases that had both a CABG and another cardiac surgery.
Exclusions:



Patient < 20 years of age
Contraindications to beta-blockers (as per The Joint Commission for beta-blockers in AMI) =
Documentation of one or more of the following:
 Allergy to beta-blockers
 Bradycardia (heart rate < 60 beats/min) on day of admission or the previous day, while not
on a beta-blocker
 Systolic blood pressure < 90 mm Hg on day of admission or the previous day, while not on a
beta-blocker
 Second- or third-degree AV heart block at any time during hospitalization or on admission, if
no pacemaker
Other reasons as documented by physician, nurse practitioner, or physician assistant
Definitions:
Beta-blockers = oral beta-blockers as specified by The Joint Commission for beta-blockers in AMI
(Appendix C: Medication Tables)
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CABG-4: Beta-blockers prescribed at discharge
Source: STS Measure 14
NQF Endorsed National Voluntary Consensus Standards for Cardiac Care
If you measured adherence to this process-of-care quality indicator and reported the results to STS for
the 12-month Reporting Time Period indicated in the survey, then use those data and results when
responding to the survey, and ignore the specifications here for this measure.
Otherwise, use these specifications to measure and report results for this measure.
Numerator: Number of isolated CABG patients discharged on beta blockers
Denominator: Total number of surgical patients with isolated CABG (ICD-9-CM procedure codes
36.10-36.19):
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.14
Aortocoronary bypass of four or more coronary arteries
36.15
Single internal mammary-coronary bypass
36.16
Double internal mammary-coronary bypass
36.17
Abdominal-coronary artery bypass
36.19
Other bypass anastamosis for heart revascularization
Note: This measure was designed to measure only isolated CABG; do not include in the numerator or
denominator any cases that had both a CABG and another cardiac surgery.
Exclusions:







Patient < 20 years of age
Transferred to another acute care hospital
Expired during hospitalization
Left against medical advice
Discharge to hospice
Contraindications to beta-blockers (as per The Joint Commission for beta-blockers in AMI) =
Documentation of one or more of the following:
 Allergy to beta-blockers

Bradycardia (heart rate < 60 beats/min) on day of discharge or the previous day, while not
on a beta-blocker
 Systolic blood pressure < 90 mm Hg on day of discharge or the previous day, while not on a
beta-blocker
 Second- or third-degree AV heart block at any time during hospitalization or on admission, if
no pacemaker
Other reasons as documented by physician, nurse practitioner, or physician assistant
Definitions:
Beta-blockers = oral beta-blockers as specified by The Joint Commission for beta-blockers in AMI
(Appendix C: Medication Tables)
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Section 3: EBHR
CABG-5: Anti-Lipid Treatment at Discharge
Source: STS Measure 15
NQF Endorsed National Voluntary Consensus Standards for Cardiac Care
If you measured adherence to this process-of-care quality indicator and reported the results to STS for
the 12-month Reporting Time Period indicated in the survey, then use those data and results when
responding to the survey, and ignore the specifications here for this measure.
Otherwise, use these specifications to measure and report results for this measure.
Numerator: Number of isolated CABG patients discharged on a statin or other pharmacologic lipidlowering regimen
Denominator: Total number of surgical patients who had undergone an isolated CABG (ICD-9-CM
procedure codes 36.10-36.19):
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.14
Aortocoronary bypass of four or more coronary arteries
36.15
Single internal mammary-coronary bypass
36.16
Double internal mammary-coronary bypass
36.17
Abdominal-coronary artery bypass
36.19
Other bypass anastamosis for heart revascularization
Note: This measure was designed to measure only isolated CABG; do not include in the numerator or
denominator any cases that had both a CABG and another cardiac surgery.
Exclusions:







Patient < 20 years of age
Transferred to another acute care hospital
Expired during hospitalization
Left against medical advice
Discharge to hospice
Contraindications to lipid-lowering agents , = Documentation of one or more of the following:
 Allergy to any of the lipid lowering products indicated in Definitions, below
 Complete biliary obstruction
 Preexisting gallbladder disease
 Active liver disease
 Unexplained persistent elevated liver function tests
 Severe renal dysfunction
 Severe biliary cirrhosis
Other reasons as documented by physician, nurse practitioner, or physician assistant
Definitions:
Lipid-lowering agents = Lovastatin, Simvastatin, Pravastatin, Fluvastatin, Atorvastatin, Cerivastatin,
Colestipol, Cholestyramine, Colesevelam, Gemfibrozil, Fenofibrate, Nicotinic Acid, (Clofibrate,
Dextrothyroxine – these two agents are not commonly used as antihyperlipidemics) and Zetia® 2
(ezetimibe)
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Section 3: EBHR
CABG-6: Prophylactic antibiotic received within 1 hour prior to CABG surgical incision
Source: SCIP INF-1b (The Joint Commission Measure Version v3.1a) Surgical Care Improvement
Project (SCIP)
NQF Endorsed National Voluntary Consensus Standards For Hospital Care
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Otherwise, use these specifications to measure and report results for this measure.
Numerator: Number of isolated CABG surgical patients with prophylactic antibiotics initiated within one
hour prior to surgical incision (two hours if receiving vancomycin or fluouroqinolone).
Denominator: All patients having had an isolated (CABG ) with no evidence of prior infection.
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.14
Aortocoronary bypass of four or more coronary arteries
36.15
Single internal mammary-coronary bypass
36.16
Double internal mammary-coronary bypass
36.17
Abdominal-coronary artery bypass
36.19
Other bypass anastamosis for heart revascularization
Note: This measure was designed for isolated CABG. Do not include cases with other cardiac
surgeries in the numerator or denominator.
Exclusions:
 Patients < 18 years of age
 Patients who had a principal or admission diagnosis suggestive of preoperative infectious diseases
 Infectious diseases 001.0-139.8
 Meningitis 320.0-326
 Ear Infection 380.0-380.23; 382.0-382.20
 Endocarditis 421.0-422.99
 Respiratory 460.0-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1
 Digestive 540-542; 575.0
 Renal 590-590.9; 595.0
 Prostate 601.0-601.9
 Gynecologic 614-614.9; 616-616.4
 Skin 680-686.9
 Musculo-skeletal 711.9-711.99; 730.0-730.99
 Fever of unknown origin 780.6
 Septic Shock 785.59
 Bacteremia 790.7
 Viremia 790.8




Patients who were receiving antibiotics within 24 hours prior to arrival (except colon surgery
patients taking oral prophylactic antibiotics)
Patients who were receiving antibiotics more than 24 hours prior to surgery (except colon surgery
patients taking oral prophylactic antibiotics)
Patients with physician/advanced practice nurse/physician assistant (physician/APN/PA)
documented infection prior to surgical procedure of interest
Patients who had other procedures requiring general or spinal anesthesia that occurred within 4
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days prior to or after the procedure of interest during this hospital stay
Patient whose procedure of interest (CABG) occurred prior to date of admission
Patients enrolled in clinical trials
Patients who have a length of stay > 120 days
Approved antibiotics:
Cefazolin, Cefuroxime or Cefamandole
If β-lactam allergy: Vancomycin or Clindamycin
CABG-7: Prophylactic antibiotics discontinued within 48 hours after CABG surgery end
Source: SCIP INF-3b (The Joint Commission Measure Version v3.1a) Surgical Care Improvement
Project (SCIP)
NQF endorsed National Voluntary Consensus Standards For Hospital Care
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Otherwise, use these specifications to measure and report results for this measure.
Numerator: Number of isolated CABG patients whose prophylactic antibiotics were discontinued within
48 hours after surgery end time.
Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes below:
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.14
Aoutocoronary bypass of four or more coronary arteries
36.15
Single internal mammary-coronary bypass
36.16
Double internal mammary-coronary bypass
36.17
Abdominal-coronary Artery Bypass
36.19
Other bypass anastamosis for heart revascularization
Note: This measure was designed to measure only isolated CABG; do not include other cardiac
surgeries in the numerator or denominator.
Exclusions:


Patients < 18 years of age
Patients who had a principal or admission diagnosis suggestive of preoperative infectious diseases
 Infectious diseases 001.0-139.8
 Meningitis 320.0-326
 Ear Infection 380.0-380.23; 382.0-382.20
 Endocarditis 421.0-422.99
 Respiratory 460.0-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1
 Digestive 540-542; 575.0
 Renal 590-590.9; 595.0
 Prostate 601.0-601.9
 Gynecologic 614-614.9; 616-616.4
 Skin 680-686.9
 Musculo-skeletal 711.9-711.99; 730.0-730.99
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Fever of unknown origin 780.6
Septic Shock 785.59
Bacteremia 790.7
Viremia 790.8
Patients who were receiving antibiotics within 24 hours prior to time of arrival (except colon surgery
patients taking oral prophylactic antibiotics)
Patients who were receiving antibiotics more than 24 hours prior to surgery (except colon surgery
patients taking oral prophylactic antibiotics
Patients who did not receive any antibiotics during hospitalization
Patients with physician/advanced practice nurse/physician assistant (physician/APN/PA)
documented infection prior to surgical procedure of interest
Patients who had other procedures requiring general or spinal anesthesia that occurred within 4
days prior to date of admission
Patient whose procedure of interest (CABG) occurred prior to date of admission
Patients enrolled in clinical trials
Patients who expired perioperatively
Patients who received urinary antiseptics only
Patients who have a length of stay > 120 days
Patients with Reasons to Extend Antibiotics
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CABG Resource Utilization Specifications: Survey
Section 3: EBHR
p.19
Because of the clinical specificity needed, specifications DIFFER from those used to count
volume of procedures elsewhere in the survey and process measure denominator counts should
not be used for that purpose.
Isolated CABG Case Count
Q20 = Number of inpatient discharges (including deaths) with ICD-9-CM PROC codes of 36.10-36.17, or
36.19 in any procedure field, excluding any cases with a concomitant valve replacement or an organ
transplant.
Inclusion criteria:
 Discharge date within Reporting Time Period
 Inpatient discharges include deaths during the hospital stay
 Any one or more primary or secondary procedure codes in the following table:
ICD-9-CM CABG procedure codes
36.10
Aortocoronary bypass for heart revascularization, not otherwise specified
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary artery
36.13
Aortocoronary bypass for three coronary artery
36.14
Aortocoronary bypass for four or more coronary arteries
36.15
Single internal mammary –coronary artery bypass
36.16
Double internal mammary –coronary artery bypass
36.17
Abdominal-coronary artery bypass
36.19
Other bypass anastomosis for heart revascularization
Exclusions:
 Patient age < 18
 Cases with MDC 14 (pregnancy, childbirth, and puerperium
 Any one or more primary or secondary procedure codes in the following tables (valve
replacement or major organ transplantation):
ICD-9-CM codes for valve replacement or repair:
35.10
Open heart valvuloplasty without replacement, unspecified valve
35.11
Open heart valvuloplasty of aortic valve without replacement
35.12
Open heart valvuloplasty of mitral valve without replacement
35.13
Open heart valvuloplasty of pulmonary valve without replacement
35.14
Open heart valvuloplasty of tricuspid valve without replacement
35.20
Replacement of unspecified heart valve
35.21
Replacement of aortic valve with tissue graft
35.22
Other replacement of mitral valve with tissue graft
35.23
Replacement of mitral valve with tissue graft
35.24
Other replacement of mitral valve
35.25
Replacement of pulmonary valve with tissue graft
35.26
Other replacement of pulmonary valve
35.27
Replacement of tricuspid valve with tissue graft
35.28
Other replacement of tricuspid valve
ICD-9-CM
50.51
50.59
52.80
procedure codes for major organ transplantation:
Auxiliary liver transplant
Other transplant of liver
Pancreatic transplant, not otherwise specified
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52.82
52.83
55.61
55.69
33.50
33.51
33.52
Section 3: EBHR
Homotransplant of pancreas
Heterotransplant of pancreas
Renal autotransplantation
Other kidney transplantation
Lung transplant, not otherwise specified
Unilateral lung transplant
Bilateral lung transplant
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Readmission Rate
(also applied to PCI, AMI and Pneumonia)
CABG Q21, PCI Q15, AMI Q8, Pneumonia Q7
For each respective procedure/condition, count how many of those cases counted and reported in
Q20(CABG), Q14(PCI), Q7(AMI), Q6(Pneum) per the “Case Count” specifications, were followed by one
(or more) readmissions for any cause to your (same) hospital within 14 days of discharge of those cases.
Note: In the Leapfrog Hospital Survey, there is not the opportunity to enter a code for ‘missing
data’. The values of 0 and 9999 are both considered to be numerical values and will be interpreted
as the number of readmissions your hospital experienced over the reporting period.
Some clarifying notes on readmissions:
1. Consider a case to be followed by a readmission if the patient is re-admitted anytime within the
14 days following the discharge date of the original case, counting days from discharge date to
re-admission date, not counting discharge date but counting re-admission date.
Example: CABG case is discharged 7/04/2010 and patient is readmitted to same hospital for any
reason 7/18/2010; count the CABG case as being followed by a readmission. But CABG case
discharged 7/04/2010 and patient re-admitted 7/19/2010 does not count as CABG case followed
by a re-admission.
2. Treat the cases included in the overall case count – Q20(CABG), Q16(PCI), Q7(AMI),
Q6(Pneum) – as “index cases”. Count those cases once and only once, if followed by any
readmission(s) within fourteen days of discharge of the index case. Don’t count the number of
readmissions.
Example: CABG case discharged 7/04/2010, patient re-admitted to same hospital for any reason
on 7/12/2010, discharged 7/14/2010, and re-admitted 7/16/2010; count the 7/04/2010 discharge
once as a case followed by re-admission within 14 days.
3. Determine readmissions following, and count each index case is so, on its own merits, for each
procedure/condition separately.
Example: AMI patient with PCI discharged 8/23/2010, readmitted for CABG 9/02/2010 and
discharged 9/08/2010, re-admitted with Pneumonia 10/15/2010. Count the AMI case (once)
followed by re-admission and the PCI case (once) followed by re-admission. The CABG case was
not followed by a re-admission within 14 days.
4. Since discharge date of the index cases counted and reported in Q20(CABG), Q16(PCI),
Q7(AMI), Q6(Pneum) must fall within the Reporting Time Period, look 14 days past the end of
the Reporting Time Period to determine if any re-admission(s). If so, the index case is counted as
being followed by a re-admission.
5. Report the number of index cases followed by a re-admission at Q21(CABG), Q17(PCI),
Q8(AMI), Q7(Pneum) as a whole number. Leapfrog will calculate the readmission rate based on
this count divided by the total cases counted in Q20(CABG), Q16(PCI), Q7(AMI), Q6(Pneum).
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Geometric Mean Length of Stay
(also applied to PCI, AMI, Pneumonia)
CABG Q22, PCI Q16, AMI Q9, Pneumonia Q8
For each respective procedure/condition, report the geometric mean length of stay for the cases
counted and reported in Q20(CABG), Q14(PCI), Q7(AMI), Q6(Pneum) per the “Case Count”
specifications, above.
Length of stay for each case counts the number of inpatient days for the case from admission to
discharge, including day of admission but excluding day of discharge, except if discharged (including
died) on the same day as admission date, count one(1) day length of stay. Date of death is considered
date discharged.
The length of stay for each case is a whole number of days, with a minimum one(1) day stayed. Do not
count fractional or partial days for late discharge or temporary transfer to another facility, e.g., for testing
or procedure. Note: Patients transferred into a Medicare-certified hospice inpatient unit contiguous with
the stay should not include hospice days in the inpatient length of stay.
Since the cases counted are based on discharge date falling within the Reporting Time Period, include
any portion of a stay occurring prior to the start of the Reporting Time Period. Do not count any portion of
any stay with a discharge date after the Reporting Time Period, even if a portion of that stay occurred
during the Reporting Time Period.
Example: Reporting Time Period = 12 months ending 12/31/2010.
 Case #1 admitted 12/28/2009 discharged 1/02/2010 counts as a case with 5 days stayed,
including 4 days in 2009.
 Case #2 admitted 12/29/2010 discharged 1/03/2011 does not count as a case; no days should be
accumulated for this case for this Reporting Time Period.
The geometric mean length of stay is NOT the simple arithmetic mean of lengths of stay. (See About
the Geometric Mean later.) To compute geometric mean length of stay (GMLOS), use the link on the
‘Survey Download Materials’ page of the online survey, Computing Geometric Mean Length of Stay:
Excel Tool, and follow the instructions for Method 1 here. Alternative Methods 2 and 3 are also described
below, but not supported.
Method 1 – Using Excel Tool: Computing Geometric Mean Length of Stay:
 Access the tool from the link on the home page of the online survey. Click on the tool to open it,
or right-click to download a copy of the tool to your workstation and open that copy.
 Enter the length of stay, as a whole number (no decimals entered), for each case in the column
for the respective procedure or condition, one row for each discharge. As indicated above, a
ZERO(0)-DAY LENGTH OF STAY IS INVALID as an observation for any case.
 GMLOS is computed as data are entered. Once all the cases for a given procedure/condition are
entered, the final answer is displayed at the top of that column. Enter that value in the survey.
 As data are entered, and once data entry is complete, save the spreadsheet to a local
workstation or network drive/folder for your records, re-use, or corrections if needed. The data
and spreadsheet cannot be saved at the online survey site.
 Tips for using tool:
 Don’t delete, insert or reformat any data rows. There is room for up to 10,000 cases, far
more than needed; empty cells are not used in the calculation and can be left as is.
 Data can be keyed in one case at a time, or cut and pasted from other spreadsheets.
Lengths of stay in the source data must be whole, positive, non-zero number only. To
paste data from another source, copy it from the source and use Edit->Paste Special->
Values so that formatting in the tool is unchanged. Otherwise, any fractional or decimal
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data entries might not display in the tool and will be difficult to locate when the tool
indicates these errors in the data entry.
 Automatic recalculation is turned on and should be left on. Otherwise, the GMLOS
displayed might not be calculated for all data entered.
 If the GEOMEAN results indicate an error, see the error message just below and correct
the error. Remember to enter whole numbers only, not decimals or fractions, and no
value less than 1 for a case.
 Cells above the data entry area are locked and the sheet is protected so that users
cannot alter that area of the spreadsheet. We recommend not turning spreadsheet
protection off.
Contact the Help Desk, if questions, at https://www.leapfroghospitalsurvey.org/helpdesk.
Method 2 – Statistical software packages:
 Statistical software packages like SAS and SPSS provide a geometric mean (GEOMEAN)
procedure. Make sure that each observation of length of stay for a case is a whole, positive, nonzero number when computing the geometric mean for the discharges included.
 Use the rounding rule to round the result to the nearest two decimal places of precision, e.g., 4.32
The Help Desk cannot provide support for inquiries about how to use statistical software tools or
packages to compute this statistic.
Method 3 – Using logs to compute geometric mean (not recommended)
 The length of stay for each case must be a whole, positive, non-zero number for each discharge’s
length of stay (observation).
 For each observation, take the logarithm of the length of stay (base 10 or natural log). Maintain at
least four(4) decimal-place precision.
 Sum the log values for each observations and divide the total by the number of observations
(discharges), still maintaining at least four(4) decimal place-precision throughout.
 Take the anti-log or log-inverse of the result, i.e., raise base 10 or base e (natural) to the result
power, continuing to maintain at least four(4) decimal-place precision in the result that is used as
the power.
 Use the rounding rule to round the result to the nearest two decimal places of precision, e.g., 4.32
The Help Desk cannot provide support for inquiries about how to apply this method.
Enter the Results in the Online Survey
Use the rounding rule to round the result to the nearest two decimal places of precision, e.g., 4.32 and
report the result in the online survey at CABG Q22, PCI Q18, AMI Q9, Pneum Q8.
About the Geometric Mean
Technically, the geometric mean is the Nth-root of the product of the length of stay for each discharge, i.e.,
(x1*x2*x3*x4*…xN) ^ (1/N). Whereas an arithmetic mean or simple average adds each observation then
divides by the number of observations, the geometric mean multiplies each observation then takes the
Nth-root of that product.
In part, because length of stay is truncated only on the left, at 1 day, a frequency distribution of lengths of
stay is skewed to the right, i.e., a “long tail” to the right, and not normally distributed in statistical terms.
Although simple average length of stay (ALOS) will tend to be normally distributed, any hospital’s ALOS
can be highly influenced by a few exceptionally long-stay cases, or outliers, especially when total case
volume (observations) are fewer. The logarithm of length of stay is more normally distributed and less
susceptible to these influences.
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Rather than remove outliers or arbitrarily truncating them at some high-end limit, using a geometric mean
length of stay reduces this effect. The severity-adjustment models developed by The Leapfrog Group use
a geometric mean length of stay, which resulted in stronger statistical models for standardizing length-ofstay comparisons from hospital to hospital.
CABG Case Counts by Risk Factor
Q23a-h = For those cases included in overall Case Count, Q20 as specified above, the number of
cases which had the specified Risk Factor present for that case, respectively.
Q#
23a
23b
23c
23d
23e
23f
23g
23h
Risk Factor
RF01
Age >=55
RF02
Male
Chronic renal disease (differs from RF34)
RF08
RF09
Chronic liver disease
COPD (differs from RF36)
RF11
RF12
Cardiomyopathy
RF19
AMI
RF33
Congestive heart failure
See Table*
None
None
RF08
RF09
RF11
RF12
RF19
RF33
n=8
If no cases have that Risk Factor present, enter 0 cases for that respective Risk Factor. Please note that
0 and 9999 are both considered numerical values, not ‘missing data’, and will be interpreted as the
number of cases with that respective risk factor.
CABG Risk Factor Definitions
RF08 – Chronic renal disease
applies to AMI, CABG, PCI
WARNING: Definition differs from RF34 – Kidney disease
Any diagnosis ICD-9-CM Diagnosis Codes
403.00
Hypertensive chronic kidney disease, malignant, without mention of renal failure
403.01
Hypertensive chronic kidney disease, malignant, with renal failure
403.10
Hypertensive chronic kidney disease, benign, without mention of renal failure
403.11
Hypertensive chronic kidney disease, benign, with renal failure
403.90
Hypertensive chronic kidney disease, unspecified, without mention of renal failure
403.91
Hypertensive chronic kidney disease, unspecified, with renal failure
404.00
Hypertensive heart and chronic kidney disease, malignant
to
404.03
404.10
Hypertensive heart and chronic kidney disease, benign
to
404.13
404.90
Hypertensive heart and chronic kidney disease, unspecified
to
404.93
582.x
Chronic nephritis
and
582.xx
583.x
Nephritis NOS
and
583.xx
585.x,
Chronic kidney disease
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586,
and
587
Section 3: EBHR
Renal failure, unspecified
Renal sclerosis, unspecified
RF09 – Chronic liver disease
applies to AMI, CABG, PCI
Any diagnosis ICD-9-CM Diagnosis Codes
571.x
Chronic liver disease/cirrhosis
and
571.xx
572.1
Portal pyemia
572.2
Hepatic coma
572.3
Portal hypertension
572.4
Hepatorenal syndrome
572.8
Other sequelae of chronic liver disease
RF11 – COPD
applies to CABG, PCI
WARNING: Definition differs from RF36 -- COPD
Any diagnosis ICD-9-CM Diagnosis Codes
491.21
Obstructive chronic bronchitis, with (acute) exacerbation
493.20
Chronic obstructive asthma without mention of status asthmaticus or acute exacerbation or
unspecified
493.21
Chronic obstructive asthma, with status asthmaticus
496
Chronic airway obstruction, not elsewhere classified
RF12 – Cardiomyopathy
applies to CABG
Any diagnosis ICD-9-CM Diagnosis Codes
425.x
Cardiomyopathy
RF19 – AMI
applies to CABG, PCI
Principal diagnosis ICD-9-CM Diagnosis Codes
410.00
Acute myocardial infarction, of anterolateral wall, episode of care unspecified
410.01
Acute myocardial infarction, of anterolateral wall, initial episode of care
410.10
Acute myocardial infarction, of other anterior wall, episode of care unspecified
410.11
Acute myocardial infarction, of other anterior wall, initial episode of care
410.20
Acute myocardial infarction, of inferolateral wall, episode of care unspecified
410.21
Acute myocardial infarction, of inferolateral wall, initial episode of care
410.30
Acute myocardial infarction, of inferoposterior wall, episode of care unspecified
410.31
Acute myocardial infarction, of inferoposterior wall, initial episode of care
410.40
Acute myocardial infarction, of other inferior wall, episode of care unspecified
410.41
Acute myocardial infarction, of other inferior wall, initial episode of care
410.50
Acute myocardial infarction, of other lateral wall, episode of care unspecified
410.51
Acute myocardial infarction, of other lateral wall, initial episode of care
410.60
Acute myocardial infarction, true posterior wall infarction, episode of care unspecified
410.61
Acute myocardial infarction, true posterior wall infarction, initial episode of care
410.70
Acute myocardial infarction, subendocardial infarction, episode of care unspecified
410.71
Acute myocardial infarction, subendocardial infarction, initial episode of care
410.80
Acute myocardial infarction, of other specified sites, episode of care unspecified
410.81
Acute myocardial infarction, of other specified sites, initial episode of care
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410.90
410.91
Section 3: EBHR
Acute myocardial infarction, unspecified site, episode of care unspecified
Acute myocardial infarction, unspecified site, initial episode of care
RF33 – Congestive heart failure
applies to AMI, CABG, PCI, Pneumonia
Any diagnosis ICD-9-CM Diagnosis Codes
428.x
and
428.xx
Heart failure
402.01
Hypertensive heart disease, malignant, with heart failure
402.11
Hypertensive heart disease, benign, with heart failure
402.91
Hypertensive heart disease, unspecified, with heart failure
404.01
Hypertensive heart and renal disease, malignant, with congestive heart failure
404.03
Hypertensive heart and renal disease, malignant, with congestive heart failure and renal failure
404.11
Hypertensive heart and renal disease, benign, with congestive heart failure
404.13
Hypertensive heart and renal disease, benign, with congestive heart failure and renal failure
404.91
Hypertensive heart and renal disease, unspecified, with congestive heart failure
404.93
Hypertensive heart and renal disease, unspecified, with congestive heart failure and renal
failure
CABG Frequently Asked Questions (FAQs)
Outcome Measures
1. My hospital’s CABG mortality outcomes are reported in one of the Leapfrog-endorsed
publicly reported statewide (CA, MA, NJ, NY, or PA) performance reports. How do I
determine our hospital’s observed and expected morality rates?
State-specific instructions for hospitals in public reporting states, including details on which
columns in the report should be referenced for answering the survey questions, are provided in
an earlier section of this document (State Specific Instructions).
2. My hospital is in one of the public outcomes reporting states but the date of the latest
mortality outcome report is not listed. Why not? Should I use the more recent results to
respond?
If there has been a recent update to your statewide CABG mortality outcomes, please contact the
Help Desk which will update this document to reflect the updated web link.
3. For CABG procedures, the scoring algorithm gives credit to hospitals for participating in
and reporting on both outcomes and process measures. Should we audit our cases
against the process of care indicators and report our results if we also participate in STS
national reporting system?
Yes, we encourage all hospitals performing CABG procedures to measure their process of care
against the process measures developed by external measure developers such as The Joint
Commission CMS, and STS. The scoring algorithm provides hospitals the opportunity to get
additional credit beyond what they get based on volume alone either by being above the all
hospital average in STS and/or by meeting the process measures for at least 80% of cases.
Process Measures
1. (General) How are “isolated CABGs” defined?
Isolated CABGs excludes patients with a concomitant valve replacement and patients with a
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transplant procedure during the stay. The list of excluded procedure codes in the CABG-2
measure may be used to identify the valve replacements.
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CABG Scoring Algorithm
Quality Score
Volume Credit (if the hospital reports a risk-adjusted outcome)
 ½ credit if overall hospital volume >= 450;
 otherwise, ¼ credit
Mortality Outcomes (if the hospital reports a risk-adjusted outcome)
 ½ additional credit if the hospital’s actual mortality rate, as indicated in the latest annual report
from STS, NNECDSG, or an approved statewide report (CA, MA, NJ, NY, PA) is better than allhospital average on a risk-adjusted basis
Survival Predictor (if the hospital does not report a risk-adjusted outcome) See details on p. 23.
 Full credit, if “Best Odds of Survival”
 ¾ credit, if “Better Odds of Survival”
 ½ credit, if “Improved Odds of Survival”
 ¼ credit, if “Lower Odds of Survival”
Process-of-Care Quality Measures
 ¼ extra credit (not to exceed full credit) if the hospital has measured and reports adhering for
80+% of cases for at least four of the seven process indicators for the procedure.
Note: If the hospital did not measure any of the seven process measures, they will be reflected as
“Did not measure” and will not receive the ¼ extra credit. If the hospital measured one or more
process measures, but reported zero (0) cases meeting the denominator criteria for all of the reported
measures, they will be scored as “No cases met criteria” and will not receive the ¼ extra credit.
Resource Utilization Score
(also applied to PCI, AMI, and Pneumonia)
For CABG, PCI, AMI, and Pneumonia, resource utilization is measured by the severity-adjusted average
length of stay inflated by the readmission rate following these cases. All inpatient discharges with the
clinical condition meeting the inclusion/exclusion criteria are included.
For each clinical condition, a hospital's average length of stay (ALOS) is adjusted for the expected impact
of differences in case severity between hospitals in the one-year period for which measures are reported.
The severity-adjustment model is a linear regression model, with the parameters derived from multi-state
historical data. The risk factors used in the model included a set of clinical, demographic and other factors
which (a) are identified from administrative data sources and (b) are clinically relevant and most
significant and material in explaining variation in the dependent variable – ALOS.
The severity-adjustment model consists of a set of statistical coefficients associated with each of several
risk factors which represent the estimated contribution (+ or -) to an expected length of stay for each case
based on presence of that factor. The proportion of total cases with each risk factor present, as reported
in each hospital’s survey responses, is used to weight those coefficients to an overall severity-adjusted
expected length of stay for the hospital’s specific mix of cases. (The models are applied by Leapfrog
when scoring each hospital’s survey responses.)
These expected lengths of stay are aggregated across all reporting hospitals and re-indexed to an overall
severity index of 1.000 representing the overall predicted length of stay across all hospitals reporting for
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that period within that clinical area, and each hospital's severity index is computed based on this reindexing.
For each clinical condition, ALOS is standardized for the likely impact that differences in case severity are
expected to influence those averages:
Standardized ALOS =
ALOS
divided by
Severity Index
This standardizes all hospital's ALOS to a common and directly comparable severity index of 1.000. The
standardized ALOS is then inflated by the readmission rate for cases in that clinical area:
Adjusted ALOS =
Std ALOS
X
(1 + Readmission Rate)
All responding hospitals are stratified into performance categories based on their severity-adjusted
average length of stay inflated by readmission rate following these cases. A hospital’s results are publicly
released and displayed on the Leapfrog Group Web site in one of five categories:
 Fully meets standards (full credit -- 4 filled bars) means the hospital is in the lowest (best)
performance category for Adjusted ALOS.
 Substantial progress (¾-credit -- 3 filled bars) means the hospital is below the midpoint
(median), but not in the lowest performance category, for Adjusted ALOS.
 Some progress (½-credit -- 2 filled bars) means the hospital is above midpoint (median), but not
in the highest performance category, for Adjusted ALOS.
 Willing to report (¼-credit -- 1 filled bar) means the hospital is in the highest (worst) performance
category for Adjusted ALOS.
 Declined to respond means the hospital did not respond to this section of the survey, or the
hospital was asked to complete the survey but has not submitted one.
Performance category cutpoints for 2011 are based on the distribution of results from surveys submitted
as of June 30, 2011. These performance category cutpoints will remain in place for the entire survey
reporting cycle, unless it is determined that there are compelling reasons to make revisions. However, at
this time, there are no plans or commitments to change the cutpoints.
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Overall Efficiency Score (also applied to PCI, AMI and Pneumonia)
A hospital's resource utilization score for a high-risk surgery (CABG and PCI) or condition (AMI and
Pneumonia) is integrated with its quality score to determine an overall efficiency score. This overall score
is reported in public Leapfrog results, in addition to the individual quality and resource utilization scores.
The quality score and resource utilization score are combined to create an Overall Efficiency Score as
follows:
Resource Utilization Score
Quality Score
Fully meets
standards
Substantial
progress
Some progress
Willing to Report
Fully Meets Standards
Fully meets
standards
Fully meets
standards
Substantial
progress
Substantial
progress
Substantial Progress
Substantial
progress
Substantial
progress
Substantial
progress
Some progress
Some Progress
Substantial
progress
Some progress
Some progress
Some progress
Some progress
Willing to Report
Willing to Report
Some progress
Willing to Report
Does Not Apply:
Standard does not apply.
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CABG Section Complete
Save your Responses!
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PCI Measure References
PCI Volume: Survey
p.20
For PCI, there are two sets of ICD-9-CM codes for counting patients for each of these procedures. The
first set of codes is for counting all patients (inpatients and outpatients) who have had the procedure
(Question #1). The second set of codes for PCI is for counting just inpatient procedures (PCI Question
#2). While it is expected that most procedures would be indicated as a principal procedure given their
severity, if the procedure code is found in a secondary position, the patient can be counted if the code
qualifies according to the definition.
Do not use these codes for measuring and reporting the Nationally-Endorsed Procedure-Specific
Process Measures of Quality; use the separate specifications for those indicators. Patient
populations used for the Process Measures typically DIFFER from patient populations included
here in the volume counts.
Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volumes,
count the number of patients with any one or more of the specified procedure codes for that EBHR
procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all
procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether
the patient qualifies to be counted.
The count for the volume measures can include emergent cases as well as “elective” scheduled cases.
Q.1: All patients (inpatients and outpatients)undergoing PCI procedure
Source: The Leapfrog Group
Number of patients discharged with ICD-9-CM codes of 00.66, 36.06, or 36.07 in any procedure field.
Note: ICD-9-CM codes of 36.01, 36.02, and 36.05 were discontinued effective 10/1/2005.
Age 18 years and older.
ICD-9-CM PCI procedure codes:
00.66
Percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy
(code effective 10/1/2005)
36.06
Insertion of non-drug eluting coronary stent(s)
36.07
Insertion of drug-eluting coronary stent(s)
The following CPT-4 and/or HCPCS procedures codes may also be used to identify cases, especially
those performed on an outpatient basis at this same hospital facility.
Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other
therapeutic intervention, any method; . . .
92980
. . . single vessel.
92981
. . . each additional vessel.
Percutaneous transluminal coronary balloon angioplasty;
92982
. . . single vessel
92984
. . . each additional vessel.
Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or
without balloon angioplasty;
92995
. . . single vessel.
92996
. . . each additional vessel.
G0290
Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or
without other therapeutic intervention, any method; single vessel.
Count the case once only where ANY one or more codes above are present.
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Q.2: All inpatients undergoing the procedure
Source: The Leapfrog Group
Number of inpatients discharged with ICD-9-CM codes of 00.66, 36.06, or 36.07 in any procedure field.
Note: ICD-9-CM codes of 36.01, 36.02, and 36.05 were discontinued effective 10/1/2005.
Age 18 years and older.
ICD-9-CM PCI procedure codes:
00.66
Percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy
(code effective 10/1/2005)
36.06
Insertion of non-drug eluting coronary stent(s)
36.07
Insertion of drug-eluting coronary stent(s)
PCI Outcomes Specifications: Survey
p.20
Q. 4-7: Instructions for National Performance Measurement Reporting
Entity:
Observed
mortality rate:
ACC NCDR CathPCI (NCDR CathPCI registry outcome data)
Expected
mortality rate:
Enter your hospital’s expected mortality rate (EMR) as a percentage. Using data from
the My Hospital R4Q “Num” column on page 61 in the current NCDR CathPCI
Registry Institutional Outcomes Reports (2010Y4), EMR must be calculated by
dividing the number for Line 1999 “Expected Mortality (among eligible)” by the
number for Line 1997 “Eligible pts” to obtain the % rate for the most recent rolling
four quarters where 12 consecutive months of data was submitted (i.e., Line
1999/Line 1997).
Enter your hospital’s (actual) observed mortality rate (OMR) as a percentage. Using
data from the My Hospital R4Q “Num” column on page 61 in the current NCDR
CathPCI Registry Institutional Outcomes Reports (2010Y4), OMR must be calculated
by dividing the number for Line 1998 “Observed Mortality (among eligible)” by the
number for Line 1997 “Eligible pts” to obtain the % rate for the most recent rolling
four quarters where 12 consecutive months of data was submitted (i.e., Line
1998/Line 1997).
Q. 8 - 12: Instructions for State and Regional Registry Reporting
General State Instructions (For hospitals in MA and NY only)



For hospitals located in a state with a public release of risk-adjusted mortality outcomes, use the
information below to determine responses to PCI questions 8 – 12. Use only the public report for the
time period indicated below when responding.
Follow the links below to the appropriate public report.
Do not substitute data from reports other than those cited here when responding.
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
If you are aware of a newer public release of risk-adjusted mortality outcomes in your state, please
contact the Leapfrog Help Desk (https://www.leapfroghospitalsurvey.org/helpdesk) as soon as
possible.

Question 8 – included in public report: Determine from the public data sources cited below whether
risk-adjusted mortality outcomes were publicly reported for your hospital in the latest public data
available in your state for the time period indicated. If your hospital’s results are not included in that
source, respond “no” to this question and skip questions 9 – 12.
Question 9 – public report time period: Indicate in the survey response the 12-month reporting
period ending, as indicated below.
Question 10 – different hospital name (optional): If the public report linked below indicates a hospital
name different from the hospital name entered in the survey’s Organization Information (section 1),
indicate the hospital’s name as it appears in the public report.
Questions 11 and 12 – hospital mortality rates: For each respective procedure and the state where
the hospital is located, follow the additional instructions below for reporting observed mortality rate
and expected mortality rate in survey questions 11 and 12, respectively, for the applicable EBHR
surgical procedure.



State Specific Instructions
State:
Source:
MA
http://www.massdac.org/sites/default/files/reports/PCI%20FY2009.pdf (Figure 7.1)
No shock and NSTEMI admissions only.1
Q8:
If your hospital is not listed, answer ‘No’, and skip Q9 – Q12; else enter ‘Yes’ and continue.1
Q9:
Report 12-month Time Period ending = 092009
Q10:
Indicate hospitals name as presented in public report, if different from hospital name indicated
in Q1 of survey section 1.
Q11:
Report SMIR (%) indicated on right side of graph (Figure 7.1) as a percent with two decimalplace precision for the observed mortality rate.
Q12:
All hospitals must report 0.46% -- the statewide Unadjusted Mortality Rate from the graph
(Figure 7.1) -- as a percent with two decimal-place precision for the expected mortality rate.
This is the expected rate to which the SMIR% is comparable.2
IMPORTANT: Do not report the Expected Mortality% from Figure 7.1.
Absent an observed mortality rate, that is a measure of severity, not hospital performance.
More
Info:
http://www.massdac.org/reports/pci.html
1
Only the 14 hospitals that also provide cardiac surgery included in Figure 7.1 should report their public risk-adjusted
results. The eight pilot hospitals with cardiac surgery services performing PCI only for non-elective patients, with
cardiogenic shock or STEMI, may NOT report public results and should respond ‘No’ to Q8.
2 The Commonwealth public report does not include hospitals’ observed mortality rates. The SMIR(%) is each
hospital’s actual (observed) mortality rate, standardized (risk-adjusted) to the average case severity for all reporting
hospitals included in the report. Since the statewide un-adjusted rate reflects the same average case severity, that
“Unadjusted Mortality Rate“ must be used as the expected rate and SMIR% as the observed.
Note that O/E ratio = Observed / Expected is equal to SMIR / Unadjusted (statewide) Mortality Rate in this case.
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State:
Source:
NY
http://www.health.state.ny.us/statistics/diseases/cardiovascular/docs/pci_2006-2008.pdf
(Table 1, p. 8)
Q8:
If your hospital is not listed, answer ‘No’, and skip Q9 – Q12; else enter ‘Yes’ and continue.
Q9:
Report 12-month Time Period ending = 122008
Q10:
Indicate hospital’s name as presented in public report, if different from hospital name indicated
in Q1 of survey section 1.
Q11:
Report All Cases OMR – Observed Mortality Rate % – as indicated, maintaining two decimalplace precision.
Q12:
Report All Cases EMR – Expected Mortality Rate % – as indicated, maintaining two decimalplace precision.
More
http://www.health.state.ny.us/statistics/diseases/cardiovascular/
Info:
IMPORTANT: Disregard RAMR (Risk-Adjusted Mortality Rate) in the public report when responding to
Q11 & Q12. Report for All cases; do not report rates for non-Emergency or Emergency cases.
Instructions for Regional Registries
Entity:
Observed
mortality rate:
Expected
mortality rate:
NNECDSG (ME, NH, VT only)
Entity:
Observed
mortality rate:
Expected
mortality rate:
BMC2 (MI only)
Enter your hospital’s observed risk-adjusted mortality rate from the last page of the
report.
Enter your hospital’s predicted risk-adjusted mortality rate from the last page of the
report.
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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.
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PCI Process Measure Specifications: Survey
Section 3: EBHR
p.22
The specifications are for auditing and measuring the rate of adherence to the process measure of quality
included in the Leapfrog Hospital Survey.
Because of the clinical specificity needed, procedure and condition definitions DIFFER from those
used to count volume of procedures elsewhere in the survey and process measure denominator
counts should not be used for that purpose.
NATIONAL PERFORMANCE MEASUREMENT SYSTEMS
To reduce the reporting burden on survey respondents, every effort has been made to harmonize this
process measure with national performance measurement systems endorsed and sponsored by the
following organizations:
 The Joint Commission (TJC),
 Centers for Medicaid and Medicare Services (CMS),
Links throughout this document to The Joint Commission Appendices and Table definitions can be
located at
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures/
GENERAL INSTRUCTIONS
The specifications in this document for each of the process measures indicate whether the measure
coincides with one that your hospital may already have measured and reported to one of these national
performance measurement systems.
1. For any process measure in the Leapfrog survey that coincides with a measure specified in a
national performance measurement system, if your hospital has
 measured adherence to that process-of-care quality indicator, and
 reported the results to The Joint Commission or CMS. . .
 for the Reporting Time Period of that measure as indicated in the survey,
then . . .
Use data and results as reported to that organization for that measure for the Reporting Time
Period specified in the survey.
In this case, to the extent any specifications below differ from the specifications for reporting the data
to those organizations, rely on the specifications of that organization.
2. Otherwise, you should measure adherence to the process-of-care quality indicator using the
specifications here and use those results in responding to the survey. See also the Frequently Asked
Questions at the end related to measuring these indicators.
In either case #1 or #2, we ask that you report the number of cases in the denominator and the number of
cases where there was adherence to the measurement standard (numerator).
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In order to attain credit for EBHR Quality, your hospital will need to have a median time to Primary PCI of
60 minutes or less.
PCI-1: Median Time to Primary PCI
Source: The Joint Commission Measure AMI-8 Version v3.1a
If you measured adherence to this process-of-care quality indicator and reported the results to The Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Otherwise, use these specifications to measure and report results for this measure
Continuous Variable Statement: Time (in minutes) from hospital arrival to primary percutaneous
coronary intervention (PCI) in patients with ST-segment elevation or left bundle branch block (LBBB) on
the electrocardiogram (ECG) performed closest to hospital arrival.
Included Populations:
Discharges that have all of the following:
An ICD-9-CM Principal diagnosis code for AMI:
410.00
Anterolateral wall, acute myocardial infarction-episode of care unspecified
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.10
Other anterior wall, acute myocardial infarction-episode of care unspecified
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.20
Inferolateral wall, acute myocardial infarction-episode of care unspecified
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.30
Inferoposterior wall, acute myocardial infarction-episode of care unspecified
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.40
Other inferior wall, acute myocardial infarction-episode of care unspecified
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.50
Other lateral wall, acute myocardial infarction-episode of care unspecified
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.60
True posterior wall, acute myocardial infarction-episode of care unspecified
410.61
True posterior wall, acute myocardial infarction-initial episode
410.70
Subendocardial, acute myocardial infarction – episode of care unspecified
410.71
Subendocardial, acute myocardial infarction – initial episode
410.80
Other specified sites, acute myocardial infarction-episode of care unspecified
410.81
Other specified sites, acute myocardial infarction-initial episode
410.90
Unspecified site, acute myocardial infarction-episode of care unspecified
410.91
Unspecified site, acute myocardial infarction-initial episode
and
PCI (determined using the following ICD-9-CM procedure codes as principal or secondary procedure):
00.66
Percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy
and
ST-segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) closest to
hospital arrival
and
PCI performed within 24 hours after hospital arrival.
Excluded Populations:
 Patients less than 18 years of age
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







Section 3: EBHR
Patients who have a length of stay > 120 days
Patients enrolled in clinical trials
Patients received as a transfer from an acute care facility where they were an inpatient or
outpatient
Patients received as a transfer from one distinct unit of the hospital to another distinct unit of the
same hospital
Patients received as a transfer from the emergency department of another hospital
Patients administered fibrinolytic agent prior to PCI
PCI described as non-primary by physician, advanced practice nurse, or physician assistant
(physician/APN/PA)
Patients who did not receive PCI within 90 minutes and had a reason for delay documented by a
physician, advance practice nurse, or physician assistant (e.g., social, religious, initial concern or
refusal, cardiopulmonary arrest, balloon pump insertion, respiratory failure requiring intubation)
PCI Resource Utilization Specifications: Survey
p.23
Because of the clinical specificity needed, specifications DIFFER from those used to count
volume of procedures elsewhere in the survey and process measure denominator counts should
not be used for that purpose.
PCI Case Count
Q14 = Number of inpatient discharges with ICD-9-CM codes of 00.66, 36.06, or 36.07 in any procedure
field.
Inclusion criteria:
 Discharge date within Reporting Time Period
 Inpatient discharges include deaths during the hospital stay
 Any one or more primary or secondary procedure code in the following table:
ICD-9-CM PCI procedure codes
00.66
Percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy
Insertion of non-drug eluting coronary stent(s) (added by Leapfrog)
36.06
Insertion of drug-eluting coronary stent(s) (added by Leapfrog)
36.07
Exclusions:
 Patient age < 18
 Patients not admitted to this hospital for an inpatient stay, e.g., ambulatory procedures
Readmission Rate
See CABG section p.41
Geometric Mean Length of Stay
See CABG section p.42
PCI Case Counts by Risk Factor
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Q17a-g = For those cases included in overall Case Count, Q14 as specified above, the number of
cases which had the specified Risk Factor present for that case, respectively.
Q#
17a
17b
17c
17d
17e
17f
17g
Risk Factor
RF06
Cancer
Chronic renal disease (differs from RF34)
RF08
RF09
Chronic liver disease
COPD (differs from RF36)
RF11
RF17
CABG
RF19
AMI
RF33
Congestive heart failure
See Table*
RF06
RF08
RF09
RF11
RF17
RF19
RF33
n=7
If no cases have that Risk Factor present, enter 0 cases for that respective Risk Factor. Please note that
0 and 9999 are both considered numerical values, not ‘missing data’, and will be interpreted as the
number of cases with that respective risk factor.
PCI Risk Factor Definitions
RF06 – Cancer
applies to AMI, PCI
Any diagnosis ICD-9-CM Diagnosis Codes
140.0
Malignant neoplasms
to
208.9
RF08 – Chronic renal disease
applies to AMI, CABG, PCI
WARNING: Definition differs from RF34 – Kidney disease
Any diagnosis ICD-9-CM Diagnosis Codes
403.00
Hypertensive chronic kidney disease, malignant, without mention of renal failure
403.01
Hypertensive chronic kidney disease, malignant, with renal failure
403.10
Hypertensive chronic kidney disease, benign, without mention of renal failure
403.11
Hypertensive chronic kidney disease, benign, with renal failure
403.90
Hypertensive chronic kidney disease, unspecified, without mention of renal failure
403.91
Hypertensive chronic kidney disease, unspecified, with renal failure
404.00
Hypertensive heart and chronic kidney disease, malignant
to
404.03
404.10
Hypertensive heart and chronic kidney disease, benign
to
404.13
404.90
Hypertensive heart and chronic kidney disease, unspecified
to
404.93
582.x
Chronic nephritis
and
582.xx
583.x
Nephritis NOS
and
583.xx
585.x,
Chronic kidney disease
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586,
and
587
Section 3: EBHR
Renal failure, unspecified
Renal sclerosis, unspecified
RF09 – Chronic liver disease
applies to AMI, CABG, PCI
Any diagnosis ICD-9-CM Diagnosis Codes
571.x
Chronic liver disease/cirrhosis
and
571.xx
572.1
Portal pyemia
572.2
Hepatic coma
572.3
Portal hypertension
572.4
Hepatorenal syndrome
572.8
Other sequelae of chronic liver disease
RF11 – COPD
applies to CABG, PCI
WARNING: Definition differs from RF36 -- COPD
Any diagnosis ICD-9-CM Diagnosis Codes
491.21
Obstructive chronic bronchitis, with (acute) exacerbation
493.20
Chronic obstructive asthma without mention of status asthmaticus or acute exacerbation or
unspecified
493.21
Chronic obstructive asthma, with status asthmaticus
496
Chronic airway obstruction, not elsewhere classified
RF17 – CABG
applies to AMI, PCI
Any procedure . . .
ICD-9-CM Procedure Codes
36.10
Bypass anasthamosis for heart revascularization
to
36.19
36.2
Heart revascularization by arterial implant
or . . .
CPT-4 Procedure Codes
33510
Coronary artery bypass graft
to
33523
33533
Coronary artery bypass graft
to
33536
RF19 – AMI
applies to CABG, PCI
Principal diagnosis ICD-9-CM Diagnosis Codes
410.00
Acute myocardial infarction, of anterolateral wall, episode of care unspecified
410.01
Acute myocardial infarction, of anterolateral wall, initial episode of care
410.10
Acute myocardial infarction, of other anterior wall, episode of care unspecified
410.11
Acute myocardial infarction, of other anterior wall, initial episode of care
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410.20
410.21
410.30
410.31
410.40
410.41
410.50
410.51
410.60
410.61
410.70
410.71
410.80
410.81
410.90
410.91
Section 3: EBHR
Acute myocardial infarction, of inferolateral wall, episode of care unspecified
Acute myocardial infarction, of inferolateral wall, initial episode of care
Acute myocardial infarction, of inferoposterior wall, episode of care unspecified
Acute myocardial infarction, of inferoposterior wall, initial episode of care
Acute myocardial infarction, of other inferior wall, episode of care unspecified
Acute myocardial infarction, of other inferior wall, initial episode of care
Acute myocardial infarction, of other lateral wall, episode of care unspecified
Acute myocardial infarction, of other lateral wall, initial episode of care
Acute myocardial infarction, true posterior wall infarction, episode of care unspecified
Acute myocardial infarction, true posterior wall infarction, initial episode of care
Acute myocardial infarction, subendocardial infarction, episode of care unspecified
Acute myocardial infarction, subendocardial infarction, initial episode of care
Acute myocardial infarction, of other specified sites, episode of care unspecified
Acute myocardial infarction, of other specified sites, initial episode of care
Acute myocardial infarction, unspecified site, episode of care unspecified
Acute myocardial infarction, unspecified site, initial episode of care
RF33 – Congestive heart failure
applies to AMI, CABG, PCI, Pneumonia
Any diagnosis ICD-9-CM Diagnosis Codes
428.x
and
428.xx
Heart failure
402.01
Hypertensive heart disease, malignant, with heart failure
402.11
Hypertensive heart disease, benign, with heart failure
402.91
Hypertensive heart disease, unspecified, with heart failure
404.01
Hypertensive heart and renal disease, malignant, with congestive heart failure
404.03
Hypertensive heart and renal disease, malignant, with congestive heart failure and renal failure
404.11
Hypertensive heart and renal disease, benign, with congestive heart failure
404.13
Hypertensive heart and renal disease, benign, with congestive heart failure and renal failure
404.91
Hypertensive heart and renal disease, unspecified, with congestive heart failure
404.93
Hypertensive heart and renal disease, unspecified, with congestive heart failure and renal
failure
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PCI Frequently Asked Questions (FAQs)
1. Should my hospital count outpatient PCI cases for the hospital volume count?
Yes, outpatient PCI procedures done at your hospital site by the same physicians and teams that
do inpatient PCI procedures count toward the overall volume threshold. The idea is to give credit
for experience by surgery teams. Procedures performed elsewhere, such as at hospital-affiliated
satellite centers should not be included in the hospital volume count.
2. My hospital’s PCI mortality outcomes are reported in one of the Leapfrog-endorsed
publicly reported statewide (MA or NY) performance reports. How do I determine our
hospital’s observed and expected morality rates?
Data from the respective state’s most recently available, publicly-reported results were compiled
from those public sources by The Leapfrog Group for purposes of hospital self-reporting in this
survey. Results for all hospitals in those publicly-reported results and detailed instructions on
which columns in the report should be referenced for answering the survey questions are
provided in an earlier section of this document (State Specific Instructions).
3. My hospital is in one of the public outcomes reporting states but the latest mortality
outcome report is not listed. Why not? Should I use the more recent results to respond?
If there has been a recent update to your statewide PCI mortality outcomes, please contact the
Help Desk which will update the website to reflect the new results.
4. For PCI procedures, the scoring algorithm gives credit to hospitals for participating in and
reporting on both outcomes and process measures. Should we audit our cases against the
process of care indicator and report our results if we also participate in NNECDSG. BMC2,
or NCDR CathPCI Registry national reporting systems?
Yes, we encourage all hospitals performing PCI procedures to measure their process of care
against process measures developed by external measure developers such as The Joint
Commission and CMS. The scoring algorithm provides hospitals the opportunity to get additional
credit beyond what they get based on volume alone either by being above the all hospital
average in NNECDSG/BMC2/NCDR CathPCI Registry and/or by having a median time to primary
PCI of 60 minutes or less.
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PCI Scoring Algorithm
Quality Score
Volume Credit (if the hospital reports a risk-adjusted outcome)
 ½ credit if overall hospital volume >= 400;
 otherwise, ¼ credit
Mortality Outcomes (if the hospital reports a risk-adjusted outcome)
 ½ additional credit if the hospital’s actual mortality rate, as indicated in the latest annual report
from ACC’s NCDR CathPCI Registry, NNECDSG, BMC2, or an approved statewide report (MA,
NY) is better than all-hospital average on a risk-adjusted basis
Survival Predictor (if the hospital does not report a risk-adjusted outcome) See details on p. 23.
 Full credit, if “Best Odds of Survival”
 ¾ credit, if “Better Odds of Survival”
 ½ credit, if “Improved Odds of Survival”
 ¼ credit, if “Lower Odds of Survival”
Process-of-Care Quality Measures
 ¼ extra credit (not to exceed full credit) if the hospital has measured and reports a median time to
primary PCI of 60 minutes or less (PCI-1: “Median time to Primary PCI”) .
Note: If the hospital did not measure the process measure, they will be reflected as “Did not measure”
and will not receive the ¼ extra credit. If the hospital measured the process measure, but reported
zero (0) cases meeting the inclusion/exclusion criteria, they will be scored as “No cases met criteria”
and will not receive the ¼ extra credit.
Resource Utilization Score
See CABG section, p.48
Overall Efficiency Score
See CABG section, p.50
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AVR Measure References
AVR Volume Standard: Survey
p.24
For AVR, there is only one set of codes for counting all patients who have had the procedure. While it is
expected that most procedures would be indicated as a principal procedure given their severity, if the
procedure code is found in a secondary position, the patient can be counted if the code qualifies
according to the definition.
Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volumes,
count the number of patients with any one or more of the specified procedure codes for that EBHR
procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all
procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether
the patient qualifies to be counted.
Q.1: All patients undergoing procedure
Source: The Leapfrog Group
Number of patients discharged with ICD-9-CM PROCEDURE CODES: 35.21 or 35.22 in any procedure
field.
Age 20 years and older
ICD-9-CM AVR procedure codes:
35.21
Replacement of aortic valve with tissue graft
35.22
Other replacement of aortic valve
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AVR Outcomes Specifications: Survey
Section 3: EBHR
p.24
Q. 3 - 6: Instructions for National Performance Measurement Reporting
Entity:
Observed
mortality rate:
Expected
mortality rate:
STS
See CABG section, p.26.
Q. 7-11: Instructions for Regional Registries
Entity:
Observed
mortality rate:
Expected
mortality rate:
NNECDSG (ME, NH, VT only)
See CABG section, p.29.
AVR Scoring Algorithm
Quality Score
Volume Credit (if the hospital reports a risk-adjusted outcome)
 ½ credit if overall hospital volume >= 120;
 otherwise, ¼ credit
Mortality Outcomes (if the hospital reports a risk-adjusted outcome)
 ½ additional credit if the hospital’s actual mortality rate, as indicated in the latest annual report
from STS/NNECDSG, is Better than National Average on a risk-adjusted basis.
Survival Predictor (if the hospital does not report a risk-adjusted outcome) See details on p. 23.
 Full credit, if “Best Odds of Survival”
 ¾ credit, if “Better Odds of Survival”
 ½ credit, if “Improved Odds of Survival”
 ¼ credit, if “Lower Odds of Survival”
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AAA Measure References
AAA Volume Standard: Survey
p.26
For AAA, there are two sets of ICD-9-CM codes for counting patients for each of these procedures. The
first set of codes is for counting all patients who have had the procedure (Question #1). The second set
of codes for AAA is for counting patients who have had a non-emergent or non-ruptured repair (AAA
Question #2). While it is expected that most procedures would be indicated as a principal procedure
given their severity, if the procedure code is found in a secondary position, the patient can be counted if
the code qualifies according to the definition.
Do not use these codes for measuring and reporting the Nationally-Endorsed Procedure-Specific
Process Measures of Quality; use the separate specifications for those indicators. Patient
populations used for the Process Measures typically DIFFER from patient populations included
here in the volume counts.
Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volumes,
count the number of patients with any one or more of the specified procedure codes for that EBHR
procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all
procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether
the patient qualifies to be counted.
Q.1: All patients undergoing procedure
Source: The Leapfrog Group
Number of patients discharged with ICD-9-CM codes of 38.34, 38.44, 38.64, 39.25 or 39.71 in any
procedure field.
Age 18 years and older
ICD-9-CM AAA procedure codes:
38.34
Resection of aorta with anastomosis
38.44
Resection of abdominal aorta with replacement
38.64
Other excision of abdominal aorta
39.25
Aorta-iliac-femoral bypass
39.71
Endovascular implementation of graft in abdominal aorta
Exclude cases:
MDC 14 (pregnancy, childbirth, and puerperium)
MDC 15 (newborns and other neonates)
Q.2: Patients with an unruptured AAA procedure
Source: The Leapfrog Group
Number of patients discharged with ICD-9-CM codes of 38.34, 38.44, 38.64, 39.25 or 39.71 in any
procedure field with a diagnosis of AAA in any field.
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Age 18 years and older
ICD-9-CM AAA procedure codes:
38.34
Resection of aorta with anastomosis
38.44
Resection of abdominal aorta with replacement
38.64
Other excision of abdominal aorta
39.25
Aorta-iliac-femoral bypass
39.71
Endovascular implementation of graft in abdominal aorta
AND
ICD-9-CM Diagnosis Codes
441.4
Abdominal aneurysm without mention of rupture
441.9
Aortic aneurysm of unspecified site without rupture
MDC
MDC
Exclude cases:
14 (pregnancy, childbirth, and puerperium)
15 (newborns and other neonates)
AAA Process Measure Specifications: Survey
p.27
AAA-1: Perioperative beta blocker for patients on beta blockers prior to arrival
Source: The Joint Commission Measure SCIP-Card-2 Version v3.1a
Note: This Joint Commission measure applies to all surgical patients on beta blockers prior to arrival.
However, for purposes of reporting to this survey, please report only on patients who have undergone
elective AAA repair.
Numerator: Total number of Elective AAA repair patients on beta-blocker therapy prior to arrival who
received beta-blockers during the perioperative period.
Denominator: Total number of Elective AAA repair patients on beta-blocker therapy prior to arrival
Principal or secondary discharge diagnosis of Elective AAA Repair determined using the following:
ICD-9 PROCEDURE CODES for non-ruptured AAA
38.34
Resection of aorta with anastomosis
38.44
Resection of abdominal aorta, with replacement
38.64
Other excision of aorta
39.71
Endovascular implantation of graft in abdominal aorta
AND
ICD-9 DIAGNOSIS CODES for unruptured AAA
441.4
Aortic aneurysm without mention of rupture
441.9
Aortic aneurysm of unspecified site without mention of rupture
Exclusions:
 Patient who are less than 18 years of age.
 Patients who have a length of stay > 120 days
 Patients whose ICD-9-CM principal procedure was performed entirely by laparoscope.
 Patients enrolled in clinical trials.
 Patients whose ICD-9-CM principal procedure occurred prior to the date of admission.
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


Section 3: EBHR
Patients who expired during the perioperative period.
Pregnant patients taking a beta-blocker prior to arrival.
Patients with a documented Reason for Not Administering Beta-Blocker Perioperative
Definitions:
Beta-blockers = oral or IV beta-blockers as specified by The Joint Commission for beta-blockers in AMI
(Appendix C: Medication Tables)
AAA Frequently Asked Questions (FAQs)
Process Measures
1. (Indicator 1) The numerator is defined as the number of patients undergoing elective AAA
repair who received beta-blockers during the perioperative period. What is the defined
time period for “perioperative period”?
Perioperative period= 24 hours prior to surgical incision through discharge from post-anesthesia
care/recovery. If the patient is discharged from surgery and admitted to a location other than the
PACU/recovery, than the perioperative period ends a maximum of six hours after arrival to the
non-PACU recovery area.
For a patient who is a chronic user of beta-blockers, that patient should then receive the regular
dose at the normal period of administration, regardless if the dose should fall on the night prior to
surgery or in the morning before surgery.
2. (Indicator 1) We counted patients as a yes who took their regular AM dose at home before
coming in for surgery. Is this correct?
Yes.
AAA Scoring Algorithm
Quality Score
Survival Predictor: See details on p. 23.
 Full credit, if “Best Odds of Survival”
 ¾ credit, if “Better Odds of Survival”
 ½ credit, if “Improved Odds of Survival”
 ¼ credit, if “Lower Odds of Survival”
Process-of-Care Quality Measures
 ¼ extra credit (not to exceed full credit) if the hospital has measured and reports adhering for
80+% of cases for the process indicator
Note: If the hospital did not measure the process measure, they will be reflected as “Did not measure”
and will not receive the ¼ extra credit. If the hospital did measure the process measure, but reported
zero (0) cases meeting the denominator criteria for the measure, they will be scored as “No cases
met criteria” and will not receive the ¼ extra credit.
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Pancreatectomy Measure References
Pancreatectomy Volume Standard: Survey
p.28
For Pancreatectomy, there are two sets of ICD-9-CM codes for counting patients for each of these
procedures. The first set of codes is for counting all patients who have had the procedure (Question #1).
The second set of codes for Pancreatectomy are for counting patients who have had the procedure and
also had a diagnosis of cancer (Question #2). While it is expected that most procedures would be
indicated as a principal procedure given their severity, if the procedure code is found in a secondary
position, the patient can be counted if the code qualifies according to the definition.
Do not use these codes for measuring and reporting the Nationally-Endorsed Procedure-Specific
Process Measures of Quality; use the separate specifications for those indicators. Patient
populations used for the Process Measures typically DIFFER from patient populations included
here in the volume counts.
Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volumes,
count the number of patients with any one or more of the specified procedure codes for that EBHR
procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all
procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether
the patient qualifies to be counted.
The count for the volume measures can include emergent cases as well as “elective” scheduled cases.
Q.1: All patients undergoing procedure
Source: The Leapfrog Group
Number of patients discharged with ICD-9-CM codes of 52.51, 52.53, 52.6 or 52.7 in any procedure field.
Age 18 years and older.
ICD-9-CM pancreatic resection procedure codes:
52.51
Proximal pancreatectomy
52.53
Radical subtotal pancreatectomy
52.6
Total Pancreatectomy
52.7
Radical Pancreaticoduodenectomy
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Q.2: Select patients in Question #1 with a diagnosis of duodenal, biliary, or
pancreatic cancer
Source: The Leapfrog Group
Number of patients identified in Question #1 that also had an ICD-9-CM diagnosis code of 152.0-152.9 or
156.0-157.9.
ICD-9-CM duodenal, biliary, and pancreatic cancer diagnosis codes:
152.0
Malignant neoplasm of duodenum
152.1
Malignant neoplasm of jejunum
152.2
Malignant neoplasm of ileum
152.3
Malignant neoplasm of meckel's diverticulum
152.8
Malignant neoplasm of other specified sites of small intestine
152.9
Malignant neoplasm of small intestine unspecified site
156.0
Malignant neoplasm of gallbladder
156.1
Malignant neoplasm of extrahepatic bile ducts
156.2
Malignant neoplasm of ampulla of vater
156.8
Malignant neoplasm of other specified sites of gallbladder and extrahepatic bile ducts
156.9
Malignant neoplasm of biliary tract part unspecified site
157.0
Malignant neoplasm of head of pancreas
157.1
Malignant neoplasm of body of pancreas
157.2
Malignant neoplasm of tail of pancreas
157.3
Malignant neoplasm of pancreatic duct
157.4
Malignant neoplasm of islets of langerhans
157.8
Malignant neoplasm of other specified sites of pancreas
157.9
Malignant neoplasm of pancreas part unspecified
Pancreatectomy Frequently Asked Questions (FAQs)
Pancreatectomy Scoring Algorithm
Quality Score
Survival Predictor: See details on p. 23.
 Full credit, if “Best Odds of Survival”
 ¾ credit, if “Better Odds of Survival”
 ½ credit, if “Improved Odds of Survival”
 ¼ credit, if “Lower Odds of Survival”
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Esophagectomy Measure References
Esophagectomy Volume Standard: Survey
p.29
For Esophagectomy, there are two sets of ICD-9-CM codes for counting patients for each of these
procedures. The first set of codes is for counting all patients who have had the procedure (Question #1).
The second set of codes for Esophagectomy are for counting patients who have had the procedure and
also had a diagnosis of cancer (Question #2). While it is expected that most procedures would be
indicated as a principal procedure given their severity, if the procedure code is found in a secondary
position, the patient can be counted if the code qualifies according to the definition.
Do not use these codes for measuring and reporting the Nationally-Endorsed Procedure-Specific
Process Measures of Quality; use the separate specifications for those indicators. Patient
populations used for the Process Measures typically DIFFER from patient populations included
here in the volume counts.
Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volumes,
count the number of patients with any one or more of the specified procedure codes for that EBHR
procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all
procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether
the patient qualifies to be counted.
The count for the volume measures can include emergent cases as well as “elective” scheduled cases.
Q.1: All patients undergoing procedure
Source: The Leapfrog Group
Number of patients discharged with ICD-9-CM codes of 42.4, 42.40, 42.41, 42.42, or 43.99 in any
procedure field.
Age 18 years and older
ICD-9-CM esophageal resection procedure codes:
42.4
Esophagectomy
42.40
Esophagectomy, not otherwise specified
42.41
Partial esophagectomy
42.42
Total esophagectomy
43.99
Other total gastrectomy
Q.2: Select patients in Question #1 with a diagnosis of esophageal cancer
Source: The Leapfrog Group
Number of patients identified in Question #1 that also had an ICD-9-CM diagnosis code of 150.0-151.0.
ICD-9-CM esophageal cancer diagnosis codes:
150.0
Malignant neoplasm of cervical esophagus
150.1
Malignant neoplasm of thoracic esophagus
150.2
Malignant neoplasm of abdominal esophagus
150.3
Malignant neoplasm of upper third of esophagus
150.4
Malignant neoplasm of middle third of esophagus
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150.5
150.8
150.9
151.0
Section 3: EBHR
Malignant neoplasm of lower third of esophagus
Malignant neoplasm of other specified part of esophagus
Malignant neoplasm of esophagus unspecified site
Malignant neoplasm of cardio-esophageal junction
Esophagectomy Frequently Asked Questions (FAQs)
Esophagectomy Scoring Algorithm
Quality Score
Survival Predictor: See details on p. 23.
 Full credit, if “Best Odds of Survival”
 ¾ credit, if “Better Odds of Survival”
 ½ credit, if “Improved Odds of Survival”
 ¼ credit, if “Lower Odds of Survival”
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Bariatric Surgery Measure References
Bariatric Surgery Volume Standard: Survey
p.30
For Bariatric surgery, there is only one set of codes for counting all patients who have had the procedure.
While it is expected that most procedures would be indicated as a principal procedure given their severity,
if the procedure code is found in a secondary position, the patient can be counted if the code qualifies
according to the definition.
Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volumes,
count the number of patients with any one or more of the specified procedure codes for that EBHR
procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all
procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether
the patient qualifies to be counted.
The count for the volume measures can include emergent cases as well as “elective” scheduled cases.
Note: The volume count can include outpatient cases as well, as long as the patient has a BMI>=35, the
procedure code must match one of the listed procedure codes below, and the procedure must have been
done explicitly for weight-loss purposes.
This includes updated CMS payment codes but not restricted to those codes.
Number of patients undergoing inpatient bariatric surgery with ICD-9-CM OR HCPCS PROCEDURE
CODES as shown below in any procedure field but only when in conjunction with at least one of the
following ICD-9-CM Diagnosis Codes:
v85.35
v85.36
v85.37
v85.38
v85.39
v85.4
278.01
Body mass index 35.0-35.9, adult
Body mass index 36.0-36.9, adult
Body mass index 37.0-37.9, adult
Body mass index 38.0-38.9, adult
Body mass index 39.0-39.9, adult
Body mass index 40 and over, adult
Morbid obesity
For a case to count for bariatric surgery, the patient must have a BMI>=35, the procedure code must
match one of the listed procedure codes below and the procedure must have been done explicitly for
weight-loss purposes, i.e., presence of one of these Diagnosis Codes is necessary but not sufficient for
inclusion. See Exclusion criteria below.
(Count patients only once if multiple procedures during same hospital stay.)
Age 20 years and older
ICD-9-CM procedure codes -- Gastric bypass
44.31
High or “Mason” gastric bypass
Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y) (new CMS 2/06)
44.38
44.39
Gastroenterostomy without gastrectomy
44.69
Other Repair of Stomach (includes vertical banded gastroplasty and adjustable gastric
banding -- does not include laparoscopic)
44.95
Laparoscopic gastric restrictive procedure (laparoscopic adjustable
gastric band and port insertion) (new CMS 2/06)
ICD-9-CM procedure codes -- Malabsorptive
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-- Duodenal switch
43.89
Other partial gastrectomy (includes sleeve gastrectomy)
45.50
Isolation of intestinal segment, not otherwise specified
45.51
Isolation of segment of small intestine
45.90
Intestine to intestine anastomosis not otherwise specified
45.91
Small to small Intestinal anastomosis
-- Biliopancreatic diversion
43.7
Partial gastrectomy with anastomosis to jejunum
45.50
Isolation of intestinal segment, not otherwise specified
45.51
Isolation of segment of small intestine
45.90
Intestine to intestine anastomosis not otherwise specified
45.91
Small to small Intestinal anastomosis
-- Isolated intestinal bypass
45.50
Isolation of intestinal segment, not otherwise specified
45.51
Isolation of segment of small intestine
45.90
Intestine to intestine anastomosis not otherwise specified
ICD-9-CM procedure codes -- Gastrectomy
43.89
Other Partial Gastrectomy (Sleeve)
43.5
Proximal
43.6
Distal
ICD-9-CM procedure codes -- Other
44.93
Insertion of Gastric bubble (balloon)
44.99
Gastric operation not elsewhere classified
Important Note: There is not a distinction between laparoscopic and open biliopancreatic diversion
(BPD) with duodenal switch (DS) for the inpatient setting. The codes would apply to the open approach as
follows:
ICD-9-CM procedure codes
43.89
Other partial gastrectomy
45.51
Isolation of segment of small intestine, and
45.91
Small to small intestinal anastomosis
Healthcare Common Procedure Coding System (HCPCS):
43770
Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band
(gastric band and subcutaneous port components)
43644
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y
gastroenterostomy (roux limb 150 cm or less)
43645
Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not
report 43645 in conjunction with 49320, 43847)
43845
Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy
and ileoieostomy (50 to 100 cm common switch)
43846
Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or
less Roux-en-Y gastroenterostomy. (For greater than 150 cm, use 43847) ( For laparoscopic
procedure, use 43644)
43847
With small intestine reconstruction to limit absorption
Exclude cases:
Procedure was performed for other reason than weight loss or morbid obesity, e.g., cancer,
gastric or peptic ulcer
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Bariatric Surgery Frequently Asked Questions (FAQs)
1.
Which ICD-9-CM diagnosis codes can be used by hospitals to begin identifying cases
where the procedure was performed for other reason than weight loss or morbid obesity,
e.g., cancer, gastric or peptic ulcer?
Hospitals can use the following ICD-9-DM diagnosis codes as a base for identifying cases:
(Note: This below list is intended to assist hospitals in identifying cases to exclude. It is not
intended to be an exhaustive list of all exclusions.)
151-151.9 (Stomach cancer)
150-150.9 (Esophageal cancer)
152-152.9 , 156-156.9 (Pancreatic, duodenal, biliary cancers)
153-154.0 (Colon cancer)
530.xx-538.xx (Diseases Of Esophagus, Stomach, And Duodenum), where ‘xx’ is any trailing 4 th
and 5th digit coding
Bariatric Surgery Scoring Algorithm
Scoring is based on a combination a hospital’s annual case count of bariatric surgeries and if they report
their bariatric surgical outcomes to a national performance measurement system. The total credits are
reflected in an overall result, which Leapfrog displays in its public release of survey results as filled bars
equal to the total credit:
EBHR Credit – Bariatric Surgery
Annual case count
of Bariatric
surgeries
Report to national
performance
measurement
system
Fully meets
standards
Substantial
progress
(4 filled bars)
(3 filled bars)
>=125
procedures
Report
Some progress
Willing to report
(2 filled bars)
(1 filled bar)
>=125
procedures
<125
procedures
<125 procedures
Do Not
report
Report
Do Not Report
*** Not a
scoring option
for Bariatric
surgery ***
**Note: The 125 procedure threshold is the same as the American College of Surgeons’ (ACS) threshold.
Declined to respond means:
The hospital did not respond to this section of the survey, or the hospital was asked to complete the
survey but has not submitted one.
Does Not Apply means:
The hospital does not perform Bariatric surgeries electively.
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High-Risk Deliveries Measure References
High-Risk Deliveries Volume Standard: Survey
p.31
Do not use these codes for measuring and reporting the Nationally-Endorsed Procedure-Specific
Process Measures of Quality; use the separate specifications for those indicators. Patient
populations used for the Process Measures typically DIFFER from patient populations included
here in the volume counts.
Use only ICD-9-CM codes as indicated in the each specification. When calculating hospital volumes,
count the number of patients with any one or more of the specified procedure codes for that EBHR
procedure, subject to the other inclusion/exclusion criteria below. Patient age restrictions apply to all
procedures. Additionally, presence or absence of certain diagnosis codes may further determine whether
the patient qualifies to be counted.
The count for the volume measures can include emergent cases as well as “elective” scheduled cases.
Source: The Leapfrog Group
(Expert Panel Members including R. Adams Dudley, MD, MBA, Ciaran S. Phibbs, PhD, John Birkmeyer,
MD, and other topic experts)
Please use the ICD-9 codes below for purposes of identifying the number of very-low birth weight babies
(VLBWB) your hospital treated.
Number of newborns admitted to the NICU with the following ICD-9-CM codes:
764.02-764.05
Light for dates without mention of malnutrition—500 gms.-1499 gms.
764.12-764.15
Light for dates with signs of fetal malnutrition -- 500 gms. - 1499 gms.
764.22-764.25
Fetal malnutrition without mention of “light for dates” -- 500 gms. -1499 gms.
764.92-764.95
Fetal growth retardation, unspecified -- 500gms. - 1499 gms.
765.02-765.05
Extreme immaturity -- 500 gms – 1499 gms
765.12-765.15
Other preterm infants -- 500 gms-1499 gms
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High-Risk Deliveries Process Measure Specifications: Survey
p.32
NICU-1: Antenatal steroids
Source: Vermont Oxford Network; see Manual of Operations1
If you measured adherence to this process-of-care quality indicator, reported the results to VON, and
continue to submit these data to VON, then use those data and results when responding to the
survey, and ignore the specifications here for this measure. See FAQs at end of this section.
Hospitals that are reporting VON results should report the values from Table 1.3 for antenatal steroids in
infants with gestational age of 24/0 to 33/6.
Otherwise, use these specifications to measure and report results for this measure.
Numerator: The number of mothers receiving antenatal steroids (corticosteroids administered IM or IV)
during pregnancy at any time prior to delivery of a very low birth weight infant.
Denominator: Total number of mothers who delivered Very Low Birth Weight Infants.
Eligible mothers = Mothers of very low birth weight infants (500 – 1499 gms) who were delivered
between 24 weeks 0 days and 32 weeks 6 days (inclusive) gestational age.
Principal or secondary discharge diagnosis of Delivery <1500 grams and gestational age between 24
weeks 0 days and 32 weeks 6 days (inclusive)
Determined using the following ICD-9 DIAGNOSIS CODES:
764.02 - 764.05 Light for dates without mention of malnutrition, 500gm – 1499gm.
764.12 - 764.15 Light for dates with signs of fetal malnutrition, 500gm – 1499gm.
764.22 - 764.25 Fetal malnutrition without mention of light for dates, 500gm – 1499gm.
764.92 - 764.95 Fetal growth retardation, unspecified, 500gm – 1499gm.
765.02 - 765.05 Extreme immaturity (usually BW < 1000gm or gestation < 28 weeks)
765.12 - 765.15 Other preterm infants, 500gm – 1499gm.
AND
765.22-765.26 Gestation age between 24 weeks and 32 weeks 6 days (inclusive)
Exclusions:
 Mother’s age < 18
 Transfers in and out
 Contraindications to steroids (below)
Definitions of Contraindications:
Contraindications to administer antenatal steroids to mothers = Documentation of one or
more of the following [NOTE: Patients having one or more of the following contraindications may
still potentially be eligible to receive the medication in which case they should not be excluded as
contraindications.]
 Maternal thyrotoxicosis
 Maternal cardiomyopathy
 Active maternal infection or chorioamnionitis
 Ruptured membrane and imminent delivery 6-12 hours
 Fetal demise
 Mother with tuberculosis
 Other contraindications as documented by physician, nurse practitioner, or physician assistant
1
VON Manual of Operations 2009, version 13.1, published Oct 2005, Revised March 9, 2006 Revised July 11, 2006,
and revised January 2009.
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Section 3: EBHR
High-Risk Deliveries Frequently Asked Questions (FAQs)
General Questions
1. Do the codes related to Leapfrog’s High-Risk Deliveries apply only to neonates?
Yes. Older patients should not be included. These codes are used to determine whether your
hospital admits or accepts transfers to your NICU of newborns whose weight or gestation period
creates higher risk. The codes are also used to count patient volume to compute the number of
very low birth weight babies treated in the NICU. This recent change is based on new evidence in
the literature.
Note: Case selection for the process measures includes both weight and gestation period.
Process Measures
2. (Indicator 1) How do we count a patient transferred here from another facility where they
received the steroids at the other facility? Is this patient excluded from our data since we
did not administer the steroids?
Yes, the patient is excluded from your data.
3. (Indicator 1) Do we only look at the admission that the patient delivers on? Some preterm
patients receive steroids and are then sent home. They then return at a later date and
deliver. Does this count as a yes?
Yes.
4. (Indicator 1) We pulled records based on the gestational age at the time of delivery not the
age at the time the steroids were given.
Yes, that is correct.
5. (Indicator 1) What is the definition for rupture of membranes?
Any breakage of the amniotic sac.
6. (Indicator 1) Some patients have prolonged premature rupture of membranes and still
receive steroids. Are these patients then excluded?
No. Only patients with premature rupture with imminent delivery within 6-12 hours should be
excluded.
7. (Indicator 1) Some patients who have contraindications still get the steroids. Do we still
exclude these patients from our counts?
Yes.
8. (Indicator 1) We cannot count moms using the Vermont Oxford Network (VON) data; they
only count infants. How do we report the process measure for use of ante-natal steroids?
If using the VON data, use the number of infants, but ONLY for those who are inborn, i.e., where
the status of the mothers is known and the mothers were delivered at your hospital. The
denominator is the number of low birth weight infants. The numerator includes those infants in the
denominator whose moms received ante-natal steroids for that delivery. If NOT relying on VON,
count mothers per these Leapfrog specifications.
9. (Indicator 1) When using VON reports, what time period should we use?
If using VON data to report your hospital’s adherence to this process measure, use the most
recent 12 months available. If relying on a report from VON, use the most recently available
report, so long as it is based on a 12-month period that ends not more than 24 months prior to
your submitting a survey AND your hospital continues to participate in and submit these data to
VON.
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10. (Indicator 1) Why are the measure specifications given in this document for the NICU-1
Antenatal Steroid measure slightly different from the measure specifications that VON
uses?
In order to have hospitals self-report this measure, some small adjustments to the VON measures
specifications were needed, including the specifications for birthweight and gestational age. For
example, VON measures antenatal steroid compliance for babies with birthweights of 501-1500
grams, however, the ICD-9 codes that are available to self-reporting hospitals are for birthweights
500-1499. As a reminder, hospitals that are using the VON report to report to Leapfrog should
adhere to the VON measure specifications.
High-Risk Deliveries Scoring Algorithm
Scoring is based on a combination a hospital’s annual patient count of very-low birth weight infants and,
where applicable, adherence to the process of care measure for high-risk deliveries. The total credits are
reflected in an overall result, which Leapfrog displays in its public release of survey results as filled bars
equal to the total credit:
EBHR Credit – High-Risk Deliveries/Newborns
Fully meets
standards
(4 filled bars)
NICU annual
patient count
>=50 VLBW infants
Ante-natal
steroid process
measure
Adhere*
Substantial
progress
Some progress
Willing to report
(3 filled bars)
(2 filled bars)
(1 filled bar)
>=50 VLBW infants
< 50 VLBW infants
or no NICU
<50 VLBW infants
or no NICU
Not adhere*
or
Did not measure**
Or
No cases met
criteria**
Not adhere*
or
Did not measure**
Or
No cases met
criteria**
Adhere*
* Measured and reported adherence to guideline for 80%+ of eligible patients.
** If the hospital did not measure the process measure, they will be reflected as “Did not measure”. If the
hospital did measure the process measure, but reported zero (0) cases meeting the denominator criteria
for the measure, they will be scored as “No cases met criteria”.
Declined to respond means:
The hospital did not respond to this section of the survey, or the hospital was asked to complete the
survey but has not submitted one.
Does Not Apply means:
The hospital does not electively admit high-risk deliveries (answered No to #1).
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Section 3: EBHR
High-risk Deliveries Section Complete
Save your Responses!
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Section 4: CACs
Section 4: 2011 Common Acute Conditions (CAC)
What’s New in the 2011 Survey
In section 4, the following changes have been made:
1. Hospitals that reported data to The Joint Commission for their Elective Delivery perinatal core
measure (PC-01) can use that data in reporting on the ‘Elective Deliveries before 39 weeks’
measure in the Leapfrog Hospital Survey. In addition, Leapfrog has updated the measure
specifications provided in the Leapfrog Survey Reference Book to match The Joint Commission’s
latest specifications.
2. The target for the ‘Elective Deliveries before 39 weeks’ measure has been updated to 5%.
Hospitals will need to be at or below this target to earn credit on this measure.
3. Minor updates were made to the exclusions for the AMI and Pneumonia process measures to
match The Joint Commissions’ latest measure specifications.
Change Summary since Release
None. If substantive changes are made to this section of the survey after release on April 1, they will be
documented in this Change Summary section.
December 13, 2011


Clarified the inclusion and exclusion criteria for Pneumonia question #6 (volume of Pneumonia cases).
Updated the code description for ICD-9 code V23.5 in the exclusion criteria for Elective Deliveries
Before 39 competed weeks.
June 8, 2011
Clarified the ICD-9-CM diagnosis codes that should be used for counting patients with a risk factor (AMI
and Pneumonia).
May 19, 2011
Updated the ICD-9 code definitions for Risk Factor 31 (Cirrhosis or chronic hepatitis) to reflect the
inclusion of the fifth digit for chronic hepatitis (571.4x).
April 29, 2011
The sampling instructions for the ‘Elective Deliveries Before 39 Weeks Gestation’ measure have been
updated. Hospitals that report the perinatal core measures to The Joint Commission (TJC) can use the
sampling methodology used by TJC, in lieu of the sampling methodology described by Leapfrog.
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Section 4: CACs
CAC Reporting Time Periods
When completing survey section 4, use this as a guide to the time periods for which data are to be
collected and/or reported.
Common Acute Conditions (CAC)
Surveys submitted prior to
November 1, 2011
Surveys submitted on or after
November 1, 2011
12 months ending
December 31, 2010
12 months ending
June 30, 2011
Hospitals reporting based
on data submitted to Joint
Commission or CMS:
1Q10–4Q10, when available
or
the most recent 12-month period available,
ending not more than 12 months ago
3Q10–2Q11, when available
or
the most recent 12-month period available,
ending not more than 12 months ago
Resource Utilization
Measures
12 months ending
December 31, 2010
12 months ending
June 30, 2011
12 months ending
December 31, 2010
12 months ending
June 30, 2011
Hospitals reporting based
on data submitted to Joint
Commission or CMS:
1Q10–4Q10, when available
or
the most recent 12-month period available,
ending not more than 12 months ago
3Q10–2Q11, when available
or
the most recent 12-month period available,
ending not more than 12 months ago
Resource Utilization
Measures
12 months ending
December 31, 2010
12 months ending
June 30, 2011
12 months ending
December 31, 2010
12 months ending
June 30, 2011
2Q10–1Q11, when available
or
the most recent 12-month period available,
ending not more than 12 months ago
3Q10–2Q11, when available
or
the most recent 12-month period available,
ending not more than 12 months ago
12 months ending
December 31, 2010
12 months ending
June 30, 2011
Condition
AMI
Process Measures of
Quality
Pneumonia
Process Measures of
Quality
Normal Deliveries
Outcome Measure
Hospitals reporting based
on data submitted to Joint
Commission :
Process Measures
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Section 4: CACs
AMI Measures References
AMI Volume Standard: Survey
p.34
Do not use these codes for measuring and reporting the Nationally-Endorsed Condition-Specific
Process Measures of Quality; use the separate specifications for those indicators. Patient
populations used for the Process Measures typically DIFFER from patient populations included
here in the volume counts.
You will find associated ICD-9-CM codes for counting patients with a principal diagnosis of the condition.
Please use the definitions given to assess this applicability.
Q.1: All inpatient discharges with a principal diagnosis of AMI
Source; The Joint Commission v3.1a
Number of inpatients discharged with an ICD-9-CM principal diagnosis code of 410.00-410.01, 410.10410.11, 410.20-410.21, 410.30-410.31, 410.40-410.41, 410.50-410.51, 410.60-410.61, 410.70-410.71,
410.80-410.81, or 410.90-410.91.
Age 18 years and older.
ICD-9-CM acute myocardial infarction diagnosis codes:
410.00
Anterolateral wall, acute myocardial infarction-episode of care unspecified
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.10
Other anterior wall, acute myocardial infarction-episode of care unspecified
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.20
Inferolateral wall, acute myocardial infarction-episode of care unspecified
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.30
Inferoposterior wall, acute myocardial infarction-episode of care unspecified
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.40
Other inferior wall, acute myocardial infarction-episode of care unspecified
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.50
Other lateral wall, acute myocardial infarction-episode of care unspecified
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.60
True posterior wall, acute myocardial infarction-episode of care unspecified
410.61
True posterior wall, acute myocardial infarction-initial episode
410.70
Subendocardial, acute myocardial infarction – episode of care unspecified
410.71
Subendocardial, acute myocardial infarction – initial episode
410.80
Other specified sites, acute myocardial infarction-episode of care unspecified
410.81
Other specified sites, acute myocardial infarction-initial episode
410.90
Unspecified site, acute myocardial infarction-episode of care unspecified
410.91
Unspecified site, acute myocardial infarction-initial episode
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AMI Process Measure Specifications: Survey
Section 4: CACs
p.34
The specifications are for auditing and measuring the rate of adherence to the process measures of
quality included in the Leapfrog Hospital Survey.
Because of the clinical specificity needed, procedure and condition definitions DIFFER from those
used to count volume of procedures elsewhere in the survey and process measure denominator
counts should not be used for that purpose.
NATIONAL PERFORMANCE MEASUREMENT SYSTEMS
To reduce the reporting burden on survey respondents, every effort has been made to harmonize these
process measures with national performance measurement systems endorsed and sponsored by the
following organizations:
 The Joint Commission (TJC),
 Centers for Medicaid and Medicare Services (CMS),
Links throughout this document to The Joint Commission Appendices and Table definitions can be
located at
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures/
GENERAL INSTRUCTIONS
The specifications in this document for each of the process measures indicate whether the measure
coincides with one that your hospital may already have measured and reported to one of these national
performance measurement systems.
1. For any process measure in the Leapfrog survey that coincides with a measure specified in a
national performance measurement system, if your hospital has
 measured adherence to that process-of-care quality indicator, and
 reported the results to The Joint Commission or CMS. .
 for the Reporting Time Period of that measure as indicated in the survey,
then . . .
Use data and results as reported to that organization for that measure for the Reporting Time
Period specified in the survey.
In this case, to the extent any specifications below differ from the specifications for reporting the data
to those organizations, rely on the specifications of that organization.
2. Otherwise, you should measure adherence to the process-of-care quality indicator using the
specifications here and use those results in responding to the survey.
In either case #1 or #2, we ask that you report the number of cases in the denominator and the number of
cases where there was adherence to the measurement standard (numerator).
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Section 4: CACs
AMI-1: Aspirin at Arrival
Source: The Joint Commission Measure AMI-1 Version v3.1a
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Numerator: AMI patients who received aspirin within 24 hours before or after hospital arrival
Denominator: AMI patients
Discharges with an ICD-9-CM Principal Diagnosis Code for AMI:
410.00
Anterolateral wall, acute myocardial infarction-episode of care unspecified
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.10
Other anterior wall, acute myocardial infarction-episode of care unspecified
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.20
Inferolateral wall, acute myocardial infarction-episode of care unspecified
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.30
Inferoposterior wall, acute myocardial infarction-episode of care unspecified
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.40
Other inferior wall, acute myocardial infarction-episode of care unspecified
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.50
Other lateral wall, acute myocardial infarction-episode of care
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.60
True posterior wall, acute myocardial infarction-episode of care unspecified
410.61
True posterior wall, acute myocardial infarction-initial episode
410.70
Subendocardial, acute myocardial infarction-episode of care unspecified
410.71
Subendocardial, acute myocardial infarction-initial episode
410.80
Other specified sites, acute myocardial infarction-episode of care unspecified
410.81
Other specified sites, acute myocardial infarction-initial episode
410.90
Unspecified site, acute myocardial infarction-episode of care unspecified
410.91
Unspecified site, acute myocardial infarction-initial episode
Excluded Populations:
 Patients less than 18 years of age
 Patients who have a length of stay > 120 days
 Patients with Comfort Measures Only documented on day of or day after arrival
 Patients enrolled in clinical trials
 Patients received in transfer from an acute care facility where they were an inpatient or outpatient
 Patients received as a transfer from one distinct unit of the hospital to another distinct unit of the
same hospital
 Patients received as a transfer from an emergency department of another hospital
 Patients discharged on day of arrival
 Patients discharged/transferred to another hospital for inpatient care on day of or day after arrival
 Patients who left against medical advice or discontinued care on day of or day after arrival
 Patients who expired on day of or day after arrival
 Patients discharged/transferred to a federal health care facility on day of or day after arrival
 Patients with a documented Reason for No Aspirin on Arrival
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AMI-2: Aspirin Prescribed at Discharge
Source: The Joint Commission Measure AMI-2 Version v3.1a
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Numerator: AMI patients who are prescribed aspirin at hospital discharge
Denominator: AMI patients
Discharges with an ICD-9-CM Principal Diagnosis Code for AMI:
410.00
Anterolateral wall, acute myocardial infarction-episode of care unspecified
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.10
Other anterior wall, acute myocardial infarction-episode of care unspecified
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.20
Inferolateral wall, acute myocardial infarction-episode of care unspecified
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.30
Inferoposterior wall, acute myocardial infarction-episode of care unspecified
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.40
Other inferior wall, acute myocardial infarction-episode of care unspecified
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.50
Other lateral wall, acute myocardial infarction-episode of care
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.60
True posterior wall, acute myocardial infarction-episode of care unspecified
410.61
True posterior wall, acute myocardial infarction-initial episode
410.70
Subendocardial, acute myocardial infarction-episode of care unspecified
410.71
Subendocardial, acute myocardial infarction-initial episode
410.80
Other specified sites, acute myocardial infarction-episode of care unspecified
410.81
Other specified sites, acute myocardial infarction-initial episode
410.90
Unspecified site, acute myocardial infarction-episode of care unspecified
410.91
Unspecified site, acute myocardial infarction-initial episode
Excluded Populations:
 Patients less than 18 years of age
 Patients who have a length of stay > 120 days
 Patients with Comfort Measures Only documented
 Patients enrolled in clinical trials
 Patients discharged/transferred to another hospital for inpatient care
 Patients who left against medical advice or discontinued care
 Patients who expired
 Patients discharged/transferred to a federal health care facility
 Patients discharged/transferred to hospice
 Patients with a documented Reason for No Aspirin at Discharge
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AMI-3: ACEI or ARB for LVSD
Source: The Joint Commission Measure AMI-3 Version v3.1a
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Numerator: AMI patients who are prescribed an ACEI or ARB at hospital discharge
Denominator: AMI patients with LVSD
Discharges with an ICD-9-CM Principal Diagnosis Code for AMI as defined below
AND
Chart documentation of a LVEF less than 40% or a narrative description of LVS function consistent with
moderate or severe systolic dysfunction
Discharges with an ICD-9-CM Principal Diagnosis Code for AMI:
410.00
Anterolateral wall, acute myocardial infarction-episode of care unspecified
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.10
Other anterior wall, acute myocardial infarction-episode of care unspecified
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.20
Inferolateral wall, acute myocardial infarction-episode of care unspecified
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.30
Inferoposterior wall, acute myocardial infarction-episode of care unspecified
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.40
Other inferior wall, acute myocardial infarction-episode of care unspecified
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.50
Other lateral wall, acute myocardial infarction-episode of care
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.60
True posterior wall, acute myocardial infarction-episode of care unspecified
410.61
True posterior wall, acute myocardial infarction-initial episode
410.70
Subendocardial, acute myocardial infarction-episode of care unspecified
410.71
Subendocardial, acute myocardial infarction-initial episode
410.80
Other specified sites, acute myocardial infarction-episode of care unspecified
410.81
Other specified sites, acute myocardial infarction-initial episode
410.90
Unspecified site, acute myocardial infarction-episode of care unspecified
410.91
Unspecified site, acute myocardial infarction-initial episode
Excluded Populations:
 Patients less than 18 years of age
 Patients who have a length of stay > 120 days
 Patients with Comfort Measures Only documented
 Patients enrolled in clinical trials
 Patients discharged/transferred to another hospital for inpatient care
 Patients who left against medical advice or discontinued care
 Patients who expired
 Patients discharged/transferred to a federal health care facility
 Patients discharged/transferred to hospice
 Patients with a documented Reason for No ACEI and No ARB at Discharge
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AMI-5: Beta-Blocker Prescribed at Discharge
Source: The Joint Commission Measure AMI-5 Version v3.1a
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Numerator: AMI patients who are prescribed a beta-blocker at hospital discharge
Denominator: AMI patients
Discharges with an ICD-9-CM Principal Diagnosis Code for AMI:
410.00
Anterolateral wall, acute myocardial infarction-episode of care unspecified
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.10
Other anterior wall, acute myocardial infarction-episode of care unspecified
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.20
Inferolateral wall, acute myocardial infarction-episode of care unspecified
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.30
Inferoposterior wall, acute myocardial infarction-episode of care unspecified
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.40
Other inferior wall, acute myocardial infarction-episode of care unspecified
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.50
Other lateral wall, acute myocardial infarction-episode of care
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.60
True posterior wall, acute myocardial infarction-episode of care unspecified
410.61
True posterior wall, acute myocardial infarction-initial episode
410.70
Subendocardial, acute myocardial infarction-episode of care unspecified
410.71
Subendocardial, acute myocardial infarction-initial episode
410.80
Other specified sites, acute myocardial infarction-episode of care unspecified
410.81
Other specified sites, acute myocardial infarction-initial episode
410.90
Unspecified site, acute myocardial infarction-episode of care unspecified
410.91
Unspecified site, acute myocardial infarction-initial episode
Excluded Populations:
 Patients less than 18 years of age
 Patients who have a length of stay > 120 days
 Patients with Comfort Measures Only documented
 Patients enrolled in clinical trials
 Patients discharged/transferred to another hospital for inpatient care
 Patients who left against medical advice or discontinued care
 Patients who expired
 Patients discharged/transferred to a federal health care facility
 Patients discharged/transferred to hospice
 Patients with a documented Reason for No Beta-Blocker at Discharge
AMI-8a: Primary PCI Received Within 90 Minutes of Hospital Arrival
Source: The Joint Commission Measure AMI-8a Version v3.1a
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
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Numerator: AMI patients whose time from hospital arrival to PCI is 90 minutes or less
Denominator: AMI patients with ST-elevation or LBBB on ECG who received primary PCI
Discharges with:
an ICD-9-CM Principal Diagnosis Code for AMI as defined below,
AND
ICD-9-CM of 00.66 (Percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy),
AND
ST-segment elevation or LBBB on the ECG performed closest to hospital arrival,
AND
PCI performed within 24 hours after hospital arrival.
Discharges with an ICD-9-CM Principal Diagnosis Code for AMI:
410.00
Anterolateral wall, acute myocardial infarction-episode of care unspecified
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.10
Other anterior wall, acute myocardial infarction-episode of care unspecified
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.20
Inferolateral wall, acute myocardial infarction-episode of care unspecified
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.30
Inferoposterior wall, acute myocardial infarction-episode of care unspecified
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.40
Other inferior wall, acute myocardial infarction-episode of care unspecified
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.50
Other lateral wall, acute myocardial infarction-episode of care
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.60
True posterior wall, acute myocardial infarction-episode of care unspecified
410.61
True posterior wall, acute myocardial infarction-initial episode
410.70
Subendocardial, acute myocardial infarction-episode of care unspecified
410.71
Subendocardial, acute myocardial infarction-initial episode
410.80
Other specified sites, acute myocardial infarction-episode of care unspecified
410.81
Other specified sites, acute myocardial infarction-initial episode
410.90
Unspecified site, acute myocardial infarction-episode of care unspecified
410.91
Unspecified site, acute myocardial infarction-initial episode
Excluded Populations:
 Patients less than 18 years of age
 Patients who have a length of stay > 120 days
 Patients enrolled in clinical trials
 Patients received in transfer from an acute care facility where they were an inpatient or outpatient
 Patients received as a transfer from one distinct unit of the hospital to another distinct unit of the
same hospital
 Patients received as a transfer from an emergency department of another hospital
 Patients administered fibrinolytic agent prior to PCI
 PCI described as non-primary by physician, advanced practice nurse, or physician assistant
(physician/APN/PA)
 Patients who did not receive PCI within 90 minutes and had a reason for delay documented by a
physician, advanced practice nurse, or physician assistant (e.g., social, religious, initial concern or
refusal, cardiopulmonary arrest, balloon pump insertion, respiratory failure requiring intubation).
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AMI Resource Utilization Specifications: Survey
Section 4: CACs
p.35
Because of the clinical specificity needed, specifications DIFFER from those used to count
volume of procedures elsewhere in the survey and process measure denominator counts should
not be used for that purpose.
AMI Case Count
Q7 = Number of inpatient discharges with principal diagnosis of Acute Myocardial Infarction.
Inclusion criteria:
 Discharge date within Reporting Time Period
 Inpatient discharges include deaths during the hospital stay
 A principal diagnosis code in the following table:
ICD-9-CM Diagnosis Codes
410.00
Anterolateral wall, acute myocardial infarction-episode of care unspecified
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.10
Other anterior wall, acute myocardial infarction-episode of care unspecified
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.20
Inferolateral wall, acute myocardial infarction-episode of care unspecified
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.30
Inferoposterior wall, acute myocardial infarction-episode of care unspecified
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.40
Other inferior wall, acute myocardial infarction-episode of care unspecified
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.50
Other lateral wall, acute myocardial infarction-episode of care unspecified
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.60
True posterior wall, acute myocardial infarction-episode of care unspecified
410.61
True posterior wall, acute myocardial infarction-initial episode
410.70
Subendocardial, acute myocardial infarction – episode of care unspecified
410.71
Subendocardial, acute myocardial infarction – initial episode
410.80
Other specified sites, acute myocardial infarction-episode of care unspecified
410.81
Other specified sites, acute myocardial infarction-initial episode
410.90
Unspecified site, acute myocardial infarction-episode of care unspecified
410.91
Unspecified site, acute myocardial infarction-initial episode
Exclusions:
 Patient age < 18
 Deaths in ER without inpatient admission
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AMI Readmission Rate
See CABG section p.41
AMI Geometric Mean Length of Stay
See CABG section p.42
AMI Case Counts by Risk Factor
Q10a-h = For those cases included in overall Case Count, Q7 as specified above, the number of
cases which had the specified Risk Factor present for that case, respectively.
Q#
10a
10b
10c
10d
10e
10f
10g
10h
Risk Factor
RF01
Age >=55
RF06
Cancer
Chronic renal disease (differs from RF34)
RF08
RF09
Chronic liver disease
RF16
PCI
RF17
CABG
RF32
Stroke or transient ischemic attack
RF33
Congestive heart failure
See Table*
None
RF06
RF08
RF09
RF16
RF17
RF32
RF33
n=8
If no cases have that Risk Factor present, enter 0 cases for that respective Risk Factor. Please note that
0 and 9999 are both considered numerical values, not ‘missing data’, and will be interpreted as the
number of cases with that respective risk factor.
AMI Risk Factor Definitions
RF06 – Cancer
applies to AMI, PCI
Any diagnosis ICD-9-CM Diagnosis Codes
140.0
Malignant neoplasms
to
208.9
RF08 – Chronic renal disease
applies to AMI, CABG, PCI
WARNING: Definition differs from RF34 – Kidney disease
Any diagnosis ICD-9-CM Diagnosis Codes
403.00
Hypertensive chronic kidney disease, malignant, without mention of renal failure
403.01
Hypertensive chronic kidney disease, malignant, with renal failure
403.10
Hypertensive chronic kidney disease, benign, without mention of renal failure
403.11
Hypertensive chronic kidney disease, benign, with renal failure
403.90
Hypertensive chronic kidney disease, unspecified, without mention of renal failure
403.91
Hypertensive chronic kidney disease, unspecified, with renal failure
404.00
Hypertensive heart and chronic kidney disease, malignant
to
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404.03
404.10
to
404.13
404.90
to
404.93
582.x
and
582.xx
583.x
and
583.xx
585.x,
586,
and
587
Section 4: CACs
Hypertensive heart and chronic kidney disease, benign
Hypertensive heart and chronic kidney disease, unspecified
Chronic nephritis
Nephritis NOS
Chronic kidney disease
Renal failure, unspecified
Renal sclerosis, unspecified
RF09 – Chronic liver disease
applies to AMI, CABG, PCI
Any diagnosis ICD-9-CM Diagnosis Codes
571.x
Chronic liver disease/cirrhosis
and
571.xx
572.1
Portal pyemia
572.2
Hepatic coma
572.3
Portal hypertension
572.4
Hepatorenal syndrome
572.8
Other sequelae of chronic liver disease
RF16 – PCI
applies to AMI
Any procedure . . .
ICD-9-CM Procedure Codes
00.66
Percutaneous transluminal coronary angioplasty (PTCA) or coronary artherectomy
Other codes indicate single/multiple vessels (00.40-00.43) or stenting (00.45-00.48, 36.06, 36.07) but are
SECONDARY to this code and should not be used to identify a PCI.
or . . .
CPT-4 Procedure Codes
92982
Percutaneous transluminal coronary balloon angioplasty, single vessel
92984
Percutaneous transluminal coronary balloon angioplasty, additional vessels
92995
Percutaneous transluminal coronary arthrectomy w/wo balloon, single vessel
92996
Percutaneous transluminal coronary arthrectomy w/wo balloon, additional vessels
92980
Transcatheter placement of intracoronary stent(s), percutaneous, single vessel
92981
Transcatheter placement of intracoronary stent(s), percutaneous, additional vessels
RF17 – CABG
applies to AMI, PCI
Any procedure . . .
ICD-9-CM Procedure Codes
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36.10
Bypass anasthamosis for heart revascularization
to
36.19
36.2
Heart revascularization by arterial implant
or . . .
CPT-4 Procedure Codes
33510
Coronary artery bypass graft
to
33523
33533
Coronary artery bypass graft
to
33536
RF32 – Stroke or transient ischemic attack
applies to AMI, Pneumonia
Any diagnosis ICD-9-CM Diagnosis Codes
430
Subarachnoid hemorrhage
431
Intracerebral hemorrhage
432.x
Intracranial hem nec/nos
433.x1
Cerebral infarction
434.x1
Cerebral infarction
435.x
Transient cerebral ischemia
436
Acute, but ill-defined, cerebrovascular disease
RF33 – Congestive heart failure
applies to AMI, CABG, PCI, Pneumonia
Any diagnosis ICD-9-CM Diagnosis Codes
428.x
and
428.xx
Heart failure
402.01
Hypertensive heart disease, malignant, with heart failure
402.11
Hypertensive heart disease, benign, with heart failure
402.91
Hypertensive heart disease, unspecified, with heart failure
404.01
Hypertensive heart and renal disease, malignant, with congestive heart failure
404.03
Hypertensive heart and renal disease, malignant, with congestive heart failure and renal failure
404.11
Hypertensive heart and renal disease, benign, with congestive heart failure
404.13
Hypertensive heart and renal disease, benign, with congestive heart failure and renal failure
404.91
Hypertensive heart and renal disease, unspecified, with congestive heart failure
404.93
Hypertensive heart and renal disease, unspecified, with congestive heart failure and renal
failure
AMI and Pneumonia Scoring Algorithm
For AMI and Pneumonia, hospitals will receive both a score for quality and a score for resource utilization.
The two scores will be reported independently and as an overall efficiency score.
Quality Score
The quality-of-care and safety process measures are used to determine the quality score for Pneumonia
and AMI. If a hospital meets or exceeds the minimum case count for a given measure (n=10), the
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hospital’s performance on the measure is compared to quartile thresholds established from recent Joint
Commission national performance data.
Note: Performance on the measure must meet or exceed the quartile threshold to receive the
corresponding points for that quartile.
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AMI Quartile Cutpoints
Measure
Aspirin at arrival
Aspirin prescribed at discharge
ACEI or ARB for LVSD
Beta-blocker prescribed at discharge
Primary PCI received within 90 minutes of hospital arrival
Top
Quartile
(4 pts)
100.00%
100.00%
100.00%
100.00%
93.33%
Second
Quartile
(3 pts)
98.75%
98.78%
96.83%
98.86%
86.11%
Third
Quartile
(2 pts)
96.74%
96.05%
91.67%
96.55%
76.47%
Bottom
Quartile
(1 pt)
<96.74%
<96.05%
<91.67%
<96.55%
<76.47%
Top
Quartile
(4 pts)
97.41%
100.00%
97.74%
96.04%
Second
Quartile
(3 pts)
93.95%
96.55%
95.77%
91.67%
Third
Quartile
(2 pts)
87.91%
92.31%
92.73%
84.56%
Bottom
Quartile
(1 pt)
<87.91%
<92.31%
<92.73%
<84.56%
Pneumonia Quartile Cutpoints
Measure
Pneumococcal vaccination
Blood cultures performed within 24 hours
Initial Antibiotic Received Within 6 Hours of Hospital Arrival
Influenza vaccination
Note: Cutpoints are based on 3Q2008-2Q2009 The Joint Commission national data and only include hospitals with 10 or more
cases for the measure
Each process measure that meets the minimum case count is equally weighted in determining the overall
score.
A hospital’s overall score is calculated by summing the points earned on each measure and dividing it by
the product of the number of measures that meet the minimum case count and the maximum score for
each measure (4 points).
Hospitals that meet the minimum overall case count for the reporting time period (n>=30), but indicate
“No” for reporting the numerator and denominator for a measure, will earn zero (0) points for the measure
they choose not to report. The maximum score of 4 points for that measure will still apply in calculating a
hospital’s overall scoring percentage.
A hospital’s overall score (a percentage) is then compared to quartile thresholds established from
calculated overall scores from the national data to determine which category a hospital is placed:






Fully meets standards (4 filled bars) means the hospital received at least 80.0% of the possible
points.
Substantial progress (3 filled bars) means the hospital received at least 62.5% of the possible
points, but less than 80.0%.
Some progress (2 filled bars) means the hospital received at least 50.0% of the possible points,
but less than 62.5%.
Willing to report (1 filled bar) means the hospital received less than 50.0% of the possible points
Declined to respond means the hospital did not respond to this section of the survey, or the
hospital was asked to complete the survey but has not submitted one.
Does Not Apply means that the hospital reported fewer than 30 admissions over a 24-month
period for this condition.
Example 1: A hospital meets or exceeds the minimum case count on four of the five AMI quality-of-care
process measures. As such, the overall quality score for AMI will be based on 16 possible points (4
measures x 4 points) and not 20 points.
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If the hospital’s performance is in the second quartile for all four measures, they will earn a total of 12
points (3 points per measure).
A hospital’s overall score will be the total points earned (12), divided by the total possible points (16), or
75%. An overall score of 75% would place the hospital in the “Substantial progress” category.
Resource Utilization Score
See CABG section, p.48
Overall Efficiency Score
See CABG section, p.50
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AMI Section Complete
Save your Responses!
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Pneumonia Measures References
Pneumonia Volume Standard: Survey
p.37
You will find associated ICD-9-CM codes for counting patients with a principal diagnosis of the condition.
For Pneumonia, a secondary diagnosis of pneumonia, in combination with select other primary
diagnoses, is considered a principal diagnosis of pneumonia for counting purposes. Please use the
definitions given to assess this applicability.
Source: The Joint Commission v3.1a
Number of inpatients discharged with an ICD-9-CM principal diagnosis code of pneumonia (Table 1,
below)
OR
Number of inpatients discharged with an ICD-9-CM principal diagnosis code of septicemia (Table 2) OR
respiratory failure (Table 3)
AND a secondary diagnosis of pneumonia (Table 1).
Age 18 years and older.
Note: Hospitals that are members2 of the Alliance of Dedicated Cancer Centers (PPS-exempt hospitals),
and therefore do not submit Pneumonia process measure data to CMS, should report zero (0) cases for
question #1 in this section. This will result in this section of the survey being scored as “Does Not Apply”
(N/A). Alliance-member hospitals will need to complete the AMI and Normal Deliveries sections as
specified.
TABLE 1 -- ICD-9-CM pneumonia diagnosis codes:
481
Pneumococcal pneumonia (Streptococcus pneumoniae pneumonia)
482.0
Pneumonia due to Klebsiella pneumoniae
482.1
Pneumonia due to Pseudomonas
482.2
Pneumonia due to Hemophilus influenzae (H. influenzae)
482.30
Pneumonia due to Streptococcus, unspecified
482.31
Pneumonia due to Group A
482.32
Pneumonia due to Group B
482.39
Pneumonia due to other Streptococcus
482.40
Pneumonia due to Staphylococcus, unspecified
482.41
Methicillin susceptible pneumonia due to Staphylococcus aureus
2
Alliance of Dedicated Cancer Centers members include:
1. City of Hope National Medical Center; Duarte, CA
2. Kenneth Norris Jr Cancer Center; Los Angeles, CA
3. Sylvester Comprehensive Cancer Center; Miami, FL (Exclude any pneumonia admissions at the Cancer Center
from remainder of University of Miami pneumonia cases reported in the survey)
4. Lee Moffitt Cancer Center; Tampa, FL
5. Dana-Farber Cancer Institute; Boston, MA
6. Karmanos Cancer Center; Detroit, MI
7. Saint Luke's Cancer Institute; Kansas City, MO
8. Roswell Park Cancer Institute; Buffalo, NY
9. Memorial Sloan-Kettering Cancer Center; New York, NY
10. Arthur G. James Cancer Hospital; Columbus, OH
11. Fox Chase Cancer Center; Philadelphia, PA
12. M.D. Anderson Cancer Center; Houston, TX
13. Seattle Cancer Care Alliance; Seattle, WA
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482.42
482.49
482.82
482.83
482.84
482.89
482.9
483.0
483.1
483.8
485
486
Section 4: CACs
Methicillin resistant pneumonia due to Staphylococcus aureus
Pneumonia due to other Staphylococcus pneumonia
Pneumonia due to Escherichia coli (E. coli)
Pneumonia due to other gram-negative bacteria
Pneumonia due to Legionnaires’ disease
Pneumonia due to other specified bacteria
Bacterial pneumonia unspecified
Pneumonia due to Mycoplasma pneumoniae
Pneumonia due to Chlamydia
Pneumonia due to other specified organism
Bronchopneumonia, organism unspecified
Pneumonia, organism unspecified
TABLE 2 -- ICD-9-CM septicemia diagnosis codes:
038.0
Streptococcal septicemia
038.10
Staphylococcal septicemia, unspecified
038.11
Methicillin susceptible Staphylococcus aureus septicemia
038.12
Methicillin resistant Staphylococcus aureus septicemia
038.19
Other staphylococcal septicemia
038.2
Pneumococcal septicemia (Streptococcus pneumoniae septicemia)
038.3
Septicemia due to anaerobes
038.40
Septicemia due to gram-negative organism, unspecified
038.41
Septicemia due to Hemophilus influenzae (H. influenzae)
038.42
Septicemia due to Escherichia coli (E. coli)
038.43
Septicemia due to Pseudomonas
038.44
Septicemia due to Serratia
038.49
Septicemia due to other
038.8
Other specified septicemias
038.9
Unspecified septicemia
TABLE 3 -- ICD-9-CM respiratory failure diagnosis codes:
518.81
Acute respiratory failure
518.84
Acute and chronic respiratory failure
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Pneumonia Process Measure Specifications: Survey
Section 4: CACs
p.37
The specifications are for auditing and measuring the rate of adherence to the process measures of
quality included in the Leapfrog Hospital Survey.
Because of the clinical specificity needed, procedure and condition definitions DIFFER from those
used to count volume of procedures elsewhere in the survey and process measure denominator
counts should not be used for that purpose.
NATIONAL PERFORMANCE MEASUREMENT SYSTEMS
To reduce the reporting burden on survey respondents, every effort has been made to harmonize these
process measures with national performance measurement systems endorsed and sponsored by the
following organizations:
 The Joint Commission (TJC),
 Centers for Medicaid and Medicare Services (CMS),
Links throughout this document to The Joint Commission Appendices and Table definitions can be
located at:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures/
GENERAL INSTRUCTIONS
The specifications in this document for each of the process measures indicate whether the measure
coincides with one that your hospital may already have measured and reported to one of these national
performance measurement systems.
1. For any process measure in the Leapfrog survey that coincides with a measure specified in a
national performance measurement system, if your hospital has
 measured adherence to that process-of-care quality indicator, and
 reported the results to The Joint Commission or CMS. .
 for the Reporting Time Period of that measure as indicated in the survey,
then . . .
Use data and results as reported to that organization for that measure for the Reporting Time
Period specified in the survey.
In this case, to the extent any specifications below differ from the specifications for reporting the data
to those organizations, rely on the specifications of that organization.
2. Otherwise, you should measure adherence to the process-of-care quality indicator using the
specifications here and use those results in responding to the survey.
In either case #1 or #2, we ask that you report the number of cases in the denominator and the number of
cases where there was adherence to the measurement standard (numerator).
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PN-2: Pneumococcal Vaccination
Source: The Joint Commission Measure PN-2 Version v3.1a
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Numerator: Patients with pneumonia, age 65 and older, who were screened for
pneumococcal vaccine status and were vaccinated prior to discharge, if indicated
Denominator: Pneumonia patients 65 years of age and older
Discharges for patients age 65 years and older with:
1. An ICD-9-CM Principal Diagnosis Code of pneumonia as defined below (Table 1);
OR
2. an ICD-9-CM Principal Diagnosis Code of septicemia (Table 2) or respiratory failure (acute or
chronic) as defined below (Table 3),
AND
a secondary diagnosis of pneumonia (Table 1).
Table 1. ICD-9-CM Codes for Pneumonia
481
Pneumococcal pneumonia (Streptococcus pneumoniae pneumonia)
482.0
Pneumonia due to Klebsiella pneumoniae
482.1
Pneumonia due to Pseudomonas
482.2
Pneumonia due to Hemophilus influenzae (H. influenzae)
482.30
Pneumonia due to Streptococcus, unspecified
482.31
Pneumonia due to Group A
482.32
Pneumonia due to Group B
482.39
Pneumonia due to other Streptococcus
482.40
Pneumonia due to Staphylococcus, unspecified
482.41
Methicillin susceptible pneumonia due to Staphylococcus aureus
482.42
Methicillin resistant pneumonia due to Staphylococcus aureus
482.49
Pneumonia due to other Staphylococcus pneumonia
482.82
Pneumonia due to Escherichia coli (E. coli)
482.83
Pneumonia due to other gram-negative bacteria
482.84
Pneumonia due to Legionnaires’ disease
482.89
Pneumonia due to other specified bacteria
482.9
Bacterial pneumonia unspecified
483.0
Pneumonia due to Mycoplasma pneumoniae
483.1
Pneumonia due to Chlamydia
483.8
Pneumonia due to other specified organism
485
Bronchopneumonia, organism unspecified
486
Pneumonia, organism unspecified
Table 2. ICD-9-CM Codes for Septicemia
038.0
Streptococcal septicemia
038.10
Staphylococcal septicemia, unspecified
038.11
Methicillin susceptible Staphylococcus aureus septicemia
038.12
Methicillin resistant Staphylococcus aureus septicemia
038.19
Other staphylococcal septicemia
038.2
Pneumococcal septicemia (Streptococcus pneumoniae septicemia)
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038.3
038.40
038.41
038.42
038.43
038.44
038.49
038.8
038.9
Section 4: CACs
Septicemia due to anaerobes
Septicemia due to gram-negative organism, unspecified
Septicemia due to Hemophilus influenzae (H. influenzae)
Septicemia due to Escherichia coli (E. coli)
Septicemia due to Pseudomonas
Septicemia due to Serratia
Septicemia due to other
Other specified septicemias
Unspecified septicemia
Table 3. ICD-9-CM Codes for Respiratory Failure
518.81
Acute respiratory failure
518.84
Acute and chronic respiratory failure
Excluded Populations:
 Patients less than 65 years of age
 Patients who have a length of stay >120 days
 Patients with Cystic Fibrosis
 Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to
hospital arrival or anytime during this hospitalization
 Patients with Comfort Measures Only documented
 Patients enrolled in clinical trials
 Patients discharged/transferred to another hospital for inpatient care
 Patients who left against medical advice or discontinued care
 Patients who expired
 Patients discharged/transferred to a federal health care facility
 Patients discharged/transferred to hospice
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PN-3a: Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for
Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival
Source: The Joint Commission Measure PN-3a Version v3.1a
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Numerator: Number of pneumonia patients transferred or admitted to the ICU
within 24 hours of hospital arrival who had blood cultures performed within 24 hours prior to or 24 hours
after arrival at the hospital
Denominator: Pneumonia ICU patients 18 years of age and older
Discharges for patients age 18 years and older transferred or admitted to the ICU within 24 hours of
hospital arrival, with:
1. an ICD-9-CM Principal Diagnosis Code of pneumonia as defined below (Table 1);
OR
2. an ICD-9-CM Principal Diagnosis Code of septicemia or respiratory failure (acute or chronic) as
defined below (Tables 2 or 3),
AND
any ICD-9-CM Other Diagnosis Code of pneumonia (Table 1).
Table 1. ICD-9-CM Codes for Pneumonia
481
Pneumococcal pneumonia (Streptococcus pneumoniae pneumonia)
482.0
Pneumonia due to Klebsiella pneumoniae
482.1
Pneumonia due to Pseudomonas
482.2
Pneumonia due to Hemophilus influenzae (H. influenzae)
482.30
Pneumonia due to Streptococcus, unspecified
482.31
Pneumonia due to Group A
482.32
Pneumonia due to Group B
482.39
Pneumonia due to other Streptococcus
482.40
Pneumonia due to Staphylococcus, unspecified
482.41
Methicillin susceptible pneumonia due to Staphylococcus aureus
482.42
Methicillin resistant pneumonia due to Staphylococcus aureus
482.49
Pneumonia due to other Staphylococcus pneumonia
482.82
Pneumonia due to Escherichia coli (E. coli)
482.83
Pneumonia due to other gram-negative bacteria
482.84
Pneumonia due to Legionnaires’ disease
482.89
Pneumonia due to other specified bacteria
482.9
Bacterial pneumonia unspecified
483.0
Pneumonia due to Mycoplasma pneumoniae
483.1
Pneumonia due to Chlamydia
483.8
Pneumonia due to other specified organism
485
Bronchopneumonia, organism unspecified
486
Pneumonia, organism unspecified
Table 2. ICD-9-CM Codes for Septicemia
038.0
Streptococcal septicemia
038.10
Staphylococcal septicemia, unspecified
038.11
Methicillin susceptible Staphylococcus aureus septicemia
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038.12
038.19
038.2
038.3
038.40
038.41
038.42
038.43
038.44
038.49
038.8
038.9
Section 4: CACs
Methicillin resistant Staphylococcus aureus septicemia
Other staphylococcal septicemia
Pneumococcal septicemia (Streptococcus pneumoniae septicemia)
Septicemia due to anaerobes
Septicemia due to gram-negative organism, unspecified
Septicemia due to Hemophilus influenzae (H. influenzae)
Septicemia due to Escherichia coli (E. coli)
Septicemia due to Pseudomonas
Septicemia due to Serratia
Septicemia due to other
Other specified septicemias
Unspecified septicemia
Table 3. ICD-9-CM Codes for Respiratory Failure
518.81
Acute respiratory failure
518.84
Acute and chronic respiratory failure
Excluded Populations:
 Patients less than 18 years of age
 Patients who have a length of stay >120 days
 Patients with Cystic Fibrosis
 Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to
hospital arrival or anytime during this hospitalization
 Patients with Comfort Measures Only documented on day or day after arrival
 Patients enrolled in clinical trials
 Patients received as a transfer from an emergency department of another hospital
 Patients received as a transfer from an acute care facility where they were an inpatient or outpatient
 Patients received as a transfer from one distinct unit of the hospital to another distinct unit of the
same hospital
 Patients received as a transfer from an ambulatory surgery center
 Patients who had no diagnosis of pneumonia either as the ED final diagnosis/impression or direct
admission diagnosis/impression
 Patients not transferred or admitted to the ICU within 24 hours of arrival
 Patients who have duration of stay less than or equal to one day
PN-5c: Initial Antibiotic Received Within 6 Hours of Hospital Arrival
Source: The Joint Commission Measure PN-5c Version v3.1a
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Numerator: Number of pneumonia patients who received their first antibiotic dose within six hours from
hospital arrival
Denominator: Pneumonia patients 18 years of age and older
Discharges for patients age 18 years and older with:
1. an ICD-9-CM Principal Diagnosis Code of pneumonia as defined below (Table 1);
OR
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2. an ICD-9-CM Principal Diagnosis Code of septicemia or respiratory failure (acute or chronic) as
defined below (Tables 2 or 3),
AND
any ICD-9-CM Other Diagnosis Code of pneumonia (Table 1).
Table 1. ICD-9-CM Codes for Pneumonia
481
Pneumococcal pneumonia (Streptococcus pneumoniae pneumonia)
482.0
Pneumonia due to Klebsiella pneumoniae
482.1
Pneumonia due to Pseudomonas
482.2
Pneumonia due to Hemophilus influenzae (H. influenzae)
482.30
Pneumonia due to Streptococcus, unspecified
482.31
Pneumonia due to Group A
482.32
Pneumonia due to Group B
482.39
Pneumonia due to other Streptococcus
482.40
Pneumonia due to Staphylococcus, unspecified
482.41
Methicillin susceptible pneumonia due to Staphylococcus aureus
482.42
Methicillin resistant pneumonia due to Staphylococcus aureus
482.49
Pneumonia due to other Staphylococcus pneumonia
482.82
Pneumonia due to Escherichia coli (E. coli)
482.83
Pneumonia due to other gram-negative bacteria
482.84
Pneumonia due to Legionnaires’ disease
482.89
Pneumonia due to other specified bacteria
482.9
Bacterial pneumonia unspecified
483.0
Pneumonia due to Mycoplasma pneumoniae
483.1
Pneumonia due to Chlamydia
483.8
Pneumonia due to other specified organism
485
Bronchopneumonia, organism unspecified
486
Pneumonia, organism unspecified
Table 2. ICD-9-CM Codes for Septicemia
038.0
Streptococcal septicemia
038.10
Staphylococcal septicemia, unspecified
038.11
Methicillin susceptible Staphylococcus aureus septicemia
038.12
Methicillin resistant Staphylococcus aureus septicemia
038.19
Other staphylococcal septicemia
038.2
Pneumococcal septicemia (Streptococcus pneumoniae septicemia)
038.3
Septicemia due to anaerobes
038.40
Septicemia due to gram-negative organism, unspecified
038.41
Septicemia due to Hemophilus influenzae (H. influenzae)
038.42
Septicemia due to Escherichia coli (E. coli)
038.43
Septicemia due to Pseudomonas
038.44
Septicemia due to Serratia
038.49
Septicemia due to other
038.8
Other specified septicemias
038.9
Unspecified septicemia
Table 3. ICD-9-CM Codes for Respiratory Failure
518.81
Acute respiratory failure
518.84
Acute and chronic respiratory failure
Excluded Populations:
 Patients less than 18 years of age
 Patients who have a length of stay >120 days
 Patients with Cystic Fibrosis
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Section 4: CACs
Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to
hospital arrival or anytime during this hospitalization
Patients with Comfort Measures Only documented on day of or day after arrival
Patients enrolled in clinical trials
Patients received as a transfer from an emergency department of another hospital
Patients received as a transfer from an acute care facility where they were an inpatient or outpatient
Patients received as a transfer from one distinct unit of the hospital to another distinct unit of the
same hospital
Patients received as a transfer from an ambulatory surgery center
Patients who had no diagnosis of pneumonia either as the ED final diagnosis/impression or direct
admission diagnosis/impression
Patients with Diagnostic Uncertainty as defined in the Data Dictionary
Patients discharged/transferred to another hospital for inpatient care on day of or day after arrival
Patients who left against medical advice or discontinued care on day of or day after arrival
Patients who expired on day of or day after arrival
Patients discharged/transferred to a federal health care facility on day of or day after arrival
Patients who do not receive any antibiotics within 24hours after arrival or who received antibiotics
the day of arrival (prior to arrival to the hospital) or the day prior to arrival
PN-7: Influenza Vaccination
Source: The Joint Commission Measure PN-7 Version v3.1a
If you measured adherence to this process-of-care quality indicator and reported the results to Joint
Commission or CMS for the 12-month Reporting Time Period indicated in the survey, then use those
data and results when responding to the survey, and ignore the specifications here for this measure.
Numerator: Patients discharged during October, November, December, January,
February or March with pneumonia, age 50 and older, who were screened for influenza vaccine status
and were vaccinated prior to discharge, if indicated
Denominator: Pneumonia patients 50 years of age and older
Discharges during October – March for patients age 50 years and older with:
1. an ICD-9-CM Principal Diagnosis Code of pneumonia as defined below (Table 1);
OR
2. an ICD-9-CM Principal Diagnosis Code of septicemia or respiratory failure (acute or chronic) as
defined below (Tables 2 or 3),
AND
any ICD-9-CM Other Diagnosis Code of pneumonia (Table 1).
Table 1. ICD-9-CM Codes for Pneumonia
481
Pneumococcal pneumonia (Streptococcus pneumoniae pneumonia)
482.0
Pneumonia due to Klebsiella pneumoniae
482.1
Pneumonia due to Pseudomonas
482.2
Pneumonia due to Hemophilus influenzae (H. influenzae)
482.30
Pneumonia due to Streptococcus, unspecified
482.31
Pneumonia due to Group A
482.32
Pneumonia due to Group B
482.39
Pneumonia due to other Streptococcus
482.40
Pneumonia due to Staphylococcus, unspecified
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482.41
482.42
482.49
482.82
482.83
482.84
482.89
482.9
483.0
483.1
483.8
485
486
Section 4: CACs
Methicillin susceptible pneumonia due to Staphylococcus aureus
Methicillin resistant pneumonia due to Staphylococcus aureus
Pneumonia due to other Staphylococcus pneumonia
Pneumonia due to Escherichia coli (E. coli)
Pneumonia due to other gram-negative bacteria
Pneumonia due to Legionnaires’ disease
Pneumonia due to other specified bacteria
Bacterial pneumonia unspecified
Pneumonia due to Mycoplasma pneumoniae
Pneumonia due to Chlamydia
Pneumonia due to other specified organism
Bronchopneumonia, organism unspecified
Pneumonia, organism unspecified
Table 2. ICD-9-CM Codes for Septicemia
038.0
Streptococcal septicemia
038.10
Staphylococcal septicemia, unspecified
038.11
Methicillin susceptible Staphylococcus aureus septicemia
038.12
Methicillin resistant Staphylococcus aureus septicemia
038.19
Other staphylococcal septicemia
038.2
Pneumococcal septicemia (Streptococcus pneumoniae septicemia)
038.3
Septicemia due to anaerobes
038.40
Septicemia due to gram-negative organism, unspecified
038.41
Septicemia due to Hemophilus influenzae (H. influenzae)
038.42
Septicemia due to Escherichia coli (E. coli)
038.43
Septicemia due to Pseudomonas
038.44
Septicemia due to Serratia
038.49
Septicemia due to other
038.8
Other specified septicemias
038.9
Unspecified septicemia
Table 3. ICD-9-CM Codes for Respiratory Failure
518.81
Acute respiratory failure
518.84
Acute and chronic respiratory failure
Excluded Populations:
 Patients less than 50 years old
 Patients who have a Length of Stay >120 days
 Patients with Cystic Fibrosis
 Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to
hospital arrival or anytime during this hospitalization
 Patients with Comfort Measures Only documented
 Patients enrolled in clinical trials
 Patients with a secondary diagnosis of 487.0 (influenza with pneumonia)
 Patients discharged/transferred to another hospital for inpatient care
 Patients who left against medical advice or discontinued care
 Patients who expired
 Patients discharged/transferred to a federal health care facility
 Patients discharged/transferred to hospice care
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Pneumonia Resource Utilization Specifications: Survey
Section 4: CACs
p.38
Because of the clinical specificity needed, specifications DIFFER from those used to count
volume of procedures elsewhere in the survey and process measure denominator counts should
not be used for that purpose.
Pneumonia Case Count
Q6 = Number of inpatients discharged with an ICD-9-CM principal diagnosis code of pneumonia (Table
A, below)
OR
Number of inpatients discharged with an ICD-9-CM principal diagnosis code of septicemia (Table B) OR
respiratory failure (Table C)
AND a secondary diagnosis of pneumonia (Table A).
Age 18 years and older.

Table A – Pneumonia
ICD-9-CM Diagnosis Codes
481
Pneumococcal pneumonia (Streptococcus pneumoniae pneumonia)
482.0
Pneumonia due to Klebsiella pneumoniae
482.1
Pneumonia due to Pseudomonas
482.2
Pneumonia due to Hemophilus influenzae (H. influenzae)
482.30
Pneumonia due to Streptococcus, unspecified
482.31
Pneumonia due to Group A
482.32
Pneumonia due to Group B
482.39
Pneumonia due to other Streptococcus
482.40
Pneumonia due to Staphylococcus, unspecified
482.41
Methicillin susceptible pneumonia due to Staphylococcus aureus
482.42
Methicillin resistant pneumonia due to Staphylococcus aureus
482.49
Pneumonia due to other Staphylococcus pneumonia
482.82
Pneumonia due to Escherichia coli (E. coli)
482.83
Pneumonia due to other gram-negative bacteria
482.84
Pneumonia due to Legionnaires’ disease
482.89
Pneumonia due to other specified bacteria
482.9
Bacterial pneumonia unspecified
483.0
Pneumonia due to Mycoplasma pneumoniae
483.1
Pneumonia due to Chlamydia
483.8
Pneumonia due to other specified organism
485
Bronchopneumonia, organism unspecified
486
Pneumonia, organism unspecified
Table B
ICD-9-CM Diagnosis Codes – Septicemia
038.0
Streptococcal septicemia
038.10
Staphylococcal septicemia, unspecified
038.11
Methicillin susceptible Staphylococcus aureus septicemia
038.12
Methicillin resistant Staphylococcus aureus septicemia
038.19
Other staphylococcal septicemia
038.2
Pneumococcal septicemia (Streptococcus pneumoniae septicemia)
038.3
Septicemia due to anaerobes
038.40
Septicemia due to gram-negative organism, unspecified
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Table B
ICD-9-CM Diagnosis Codes – Septicemia
038.41
Septicemia due to Hemophilus influenzae (H. influenzae)
038.42
Septicemia due to Escherichia coli (E. coli)
038.43
Septicemia due to Pseudomonas
038.44
Septicemia due to Serratia
038.49
Septicemia due to other
038.8
Other specified septicemias
038.9
Unspecified septicemia
ICD-9-CM Diagnosis Codes – Respiratory Failure
518.81
Acute respiratory failure
518.84
Acute and chronic respiratory failure
Pneumonia Readmission Rate
See CABG section, p.41
Pneumonia Geometric Mean Length of Stay
See CABG section, p.42
Pneumonia Case Counts by Risk Factor
Q9a-i = For those cases included in overall Case Count, Q6 as specified above, the number of cases
which had the specified Risk Factor present for that case, respectively.
Q#
9a
9b
9c
9d
9e
9f
9g
9h
9i
Risk Factor
RF01
Age >=55
RF31
Cirrhosis or chronic hepatitis
RF32
Stroke or transient ischemic attack
RF33
Congestive heart failure
Kidney disease (differs from RF08)
RF34
COPD (differs from RF11)
RF36
RF43
Pleural effusion
RF44
Septicemia
RF45
Respiratory failure
See Table*
RF01
RF31
RF32
RF33
RF34
RF36
RF43
RF44
RF45
n=9
If no cases have that Risk Factor present, enter 0 cases for that respective Risk Factor. Please note that
0 and 9999 are both considered numerical values, not ‘missing data’, and will be interpreted as the
number of cases with that respective risk factor.
Pneumonia Risk Factor Definitions
RF31 – Cirrhosis or chronic hepatitis
applies to Pneumonia
Any diagnosis ICD-9-CM Diagnosis Codes
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571.2
571.4x
571.5
571.6
Section 4: CACs
Alcoholic cirrhosis of liver
Chronic hepatitis
Cirrhosis of liver without mention of alcohol
Biliary cirrhosis
RF32 – Stroke or transient ischemic attack
applies to AMI, Pneumonia
Any diagnosis ICD-9-CM Diagnosis Codes
430
Subarachnoid hemorrhage
431
Intracerebral hemorrhage
432.x
Intracranial hem nec/nos
433.x1
Cerebral infarction
434.x1
Cerebral infarction
435.x
Transient cerebral ischemia
436
Acute, but ill-defined, cerebrovascular disease
RF33 – Congestive heart failure
applies to AMI, CABG, PCI, Pneumonia
Any diagnosis ICD-9-CM Diagnosis Codes
428.x
and
428.xx
Heart failure
402.01
Hypertensive heart disease, malignant, with heart failure
402.11
Hypertensive heart disease, benign, with heart failure
402.91
Hypertensive heart disease, unspecified, with heart failure
404.01
Hypertensive heart and renal disease, malignant, with congestive heart failure
404.03
Hypertensive heart and renal disease, malignant, with congestive heart failure and renal failure
404.11
Hypertensive heart and renal disease, benign, with congestive heart failure
404.13
Hypertensive heart and renal disease, benign, with congestive heart failure and renal failure
404.91
Hypertensive heart and renal disease, unspecified, with congestive heart failure
404.93
Hypertensive heart and renal disease, unspecified, with congestive heart failure and renal
failure
RF34 – Kidney disease
applies to Pneumonia
WARNING: Definition differs from RF08 – Chronic renal disease
Any diagnosis ICD-9-CM Diagnosis Codes
580.x
Acute nephritis
581.x
Nephrotic syndrome
582.x
Chronic nephritis
583.x
Nephritis NOS
584.x
Acute renal failure
585.x
Chronic renal failure
586
Renal failure, unspecified
587
Renal sclerosis, unspecified
588.x
Impaired renal function
589.x
Small kidney
590.x
Kidney infection
591
Hydronephrosis
592.x
Renal/ureteral calculus
593.x
Other renal & ureteral disease
403.xx
Hypertensive renal disease
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Hypertensive heart/renal disease
RF36 – COPD
applies to Pneumonia
WARNING: Definition differs from RF11 -- COPD
Any diagnosis ICD-9-CM Diagnosis Codes
496
Chronic airway obstruction, not elsewhere classified
491.2x
Obstructive chronic bronchitis
491.8
Other chronic bronchitis
491.9
Unspecified chronic bronchitis
RF43 – Pleural effusion
applies to Pneumonia
Any diagnosis ICD-9-CM Diagnosis Codes
511.9
Unspecified pleural effusion
RF44 – Septicemia
applies to Pneumonia
Any diagnosis ICD-9-CM Diagnosis Codes
038.0
Septicemia
038.10 Staphylococcal septicemia, unspecified
038.11 Methicillin susceptible Staphylococcus aureus septicemia
038.12 Methicillin resistant Staphylococcus aureus septicemia
038.19 Other staphylococcal septicemia
038.2
Pneumococcal septicemia
038.3
Septicemia due to anaerobes
038.40 Septicemia due to gram-negative organism, unspecified
038.41 Septicemia due to hemophilus influenzae (h. influenzae)
038.42 Septicemia due to escherichia coli (e. coli)
038.43 Septicemia due to pseudomonas
038.44 Septicemia due to serratia
038.49 Other septicemia due to gram-negative organisms
038.8
Other specified septicemias
038.9
Unspecified septicemia
RF45 – Respiratory failure
applies to Pneumonia
Any diagnosis ICD-9-CM Diagnosis Codes
518.81
Acute respiratory failure
518.84
Acute and chronic respiratory failure
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Normal Deliveries Measures References
Normal Deliveries Volume Standard: Survey
p.40
Total Live Births (Q1)
The number of live births reported to your state during the reporting time period.
Alternatively, the below list of V codes can be used to identify live births, with the caution that
these codes are coded for the newborn, not the mother; likely to be found in your hospital’s birth
CIS/medical record system; but often not in claims data since normal newborn care may be
included in the mother’s claim without baby’s diagnosis coding.
V30 - Single liveborn
V31 - Twin, mate liveborn
V32 - Twin, mate stillborn
V33 - Twin, unspecified
V34 - Other multiple, mates all liveborn
V36 - Other multiple, mates live- and stillborn
V37 - Other multiple, unspecified
V39 - Unspecified
Note: This data point is simply used to qualify a hospital for further reporting of the normal
delivery measures.
Normal Deliveries Outcome Measure Specifications: Survey
p.40
Important Notes:
Note 1: Normal Deliveries-1 is an outcome measure that can be reported based on all eligible cases OR
a sufficient sample of cases as outlined in the denominator specifications.
Where possible, administrative codes have been provided to assist hospitals in abstracting the required
data for this measure. Hospitals may find their birth certificate registry data to be the most efficient source
of obtaining the needed information for this measure. Hospitals that lack data system integration and birth
certificate registry reporting capabilities may have to rely on chart review to obtain some of the needed
information.
Note 2: With the update to match The Joint Commission’s most recent specifications for the Elective
Delivery Prior to 39 weeks measure, hospitals will need to carefully review both the denominator and
numerator criteria to understand the differences from the previous survey specifications.
Normal Deliveries-1: Elective Delivery Prior to 39 Completed Weeks Gestation
Source: The Joint Commission (PC-01) v.2010B2
Denominator: All mothers (or a sufficient sample* of them) delivering newborns with >=37 weeks
of gestation completed and <39 weeks of gestation period during the reporting period with
Excluded Populations removed.
Gestational Age at delivery - Use birth certificate registry data; or use the list of exclusions to
eliminate cases with early onset of delivery and post-dates, followed by chart review to identify
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eligible cases. The Joint Commission specifications also provide guidance on methods for
determining the newborn’s gestational age.
Report this value in Q2.
If fewer than 10 cases during the reporting period, skip the next question.
*Hospitals opting to identify a sufficient sample of mothers for this measure, in lieu of full
case reporting, should follow these instructions:
1. Review your hospital’s first delivery on April 15, 2010 (or July 15, 2010 if (re)submitting a
survey after October 31, 2011).
2. Evaluate this case against the inclusion criteria; retain the case for the sample if the
delivery was at or after 259 days gestation (37 completed weeks gestation) and before
273 days gestation (39 completed weeks gestation).
3. Evaluate this case against the exclusion criteria; retain the case for the sample if it does
not meet any of the listed exclusions.
4. Move to the next delivery and evaluate for inclusion/exclusion applicability.
5. Continue through cases in sequential order until a sample of at least 100 cases is
reached, or all cases in the reporting period are reviewed, which ever comes first.
Note: Hospitals that report the perinatal core measures to The Joint Commission (TJC) can
use the sampling methodology used by TJC, in place of the sampling methodology described
above.
Excluded Populations:

Less than 8 years of age

Greater than or equal to 65 years of age

Length of stay > 120 days

Enrolled in clinical trials

Exclude any cases with one or more of the following ICD-9-CM codes in a primary or
secondary field:
042
641.01
641.11
641.21
641.31
641.81
641.91
642.01
642.02
642.11
642.12
642.21
642.22
642.31
Human immunodeficiency virus [HIV] disease
Placenta previa w/o hemorrhage, delivered w/ or w/out mention of antepartum condition
Hemorrhage from placenta previa, delivered w/ or w/out mention of antepartum condition
Premature separation of placenta, delivered, w/ or w/out mention of antepartum condition
Antepartum hemorrhage associated w/coagulation defects, delivered w/ or w/out mention
of antepartum condition
Other antepartum hemorrhage, delivered w/ or w/out mention of antepartum condition
Unspecified antepartum hemorrhage, delivered w/ or w/out mention of antepartum
condition
Benign essential hypertension complicating pregnancy, childbirth, & puerperium,
delivered w/or w/out mention of antepartum condition
Benign essential hypertension complicating pregnancy, childbirth, & puerperium,
delivered w/mention of postpartum complication
Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the
puerperium, delivered w/ or w/out mention of antepartum condition
Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the
puerperium, delivered w/mention of postpartum complication
Other pre-existing hypertension complicating pregnancy, childbirth & puerperium,
delivered w/ or w/out mention of antepartum condition
Other pre-existing hypertension complicating pregnancy, childbirth & puerperium,
delivered w/mention of postpartum complication
Transient hypertension of pregnancy, delivered w/ or w/out mention of antepartum
condition
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642.32
642.41
642.42
642.51
642.52
642.61
642.62
642.71
642.72
642.91
642.92
645.11
646.21
646.22
646.71
648.01
648.51
648.52
648.61
648.62
648.81
648.82
649.31
649.32
651.01
651.11
651.21
651.31
651.41
651.51
651.61
651.71
651.81
651.91
652.01
652.61
Section 4: CACs
Transient hypertension of pregnancy, delivered w/mention of postpartum complication
Mild or unspecified pre-eclampsia, delivered w/ or w/out mention of antepartum condition
Mild or unspecified pre-eclampsia, delivered w/mention of postpartum complication
Severe pre-eclampsia, delivered w/ or w/out mention of antepartum condition
Severe pre-eclampsia, delivered w/mention of postpartum complication
Eclampsia, delivered w/ or w/out mention of antepartum condition
Eclampsia, delivered w/mention of postpartum complication
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered w/ or
w/out mention of antepartum condition
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered
w/mention of postpartum complication
Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, delivered
w/ or w/out mention of antepartum condition
Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, delivered
w/mention of postpartum complication
Post term pregnancy, delivered, w/ or w/out mention of antepartum condition
Unspecified renal disease in pregnancy, w/out mention of hypertension, delivered w/ or
w/out mention of antepartum condition
Unspecified renal disease in pregnancy, w/out mention of hypertension, delivered
w/mention of postpartum complication
Liver disorders in pregnancy, delivered w/ or w/out mention of antepartum condition
Diabetes mellitus, delivered, with or without mention of antepartum condition
Congenital cardiovascular disorders, delivered w/ or w/out mention of antepartum
condition
Congenital cardiovascular disorders, delivered w/mention of postpartum complication
Other cardiovascular diseases, delivered w/ or w/o mention of antepartum condition
Other cardiovascular diseases, delivered w/mention of postpartum complication
Abnormal glucose tolerance, delivered w/ or w/o mention of antepartum condition
Abnormal glucose tolerance, delivered w/mention of postpartum complication
Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with
or without mention of antepartum condition
Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with
mention of postpartum complication
Multiple gestation, twin pregnancy, delivered with or without mention of antepartum
condition
Multiple gestation, triplet pregnancy, delivered with or without mention of antepartum
condition
Multiple gestation, quadruplet pregnancy, delivered with or without mention of antepartum
condition
Multiple gestation, twin pregnancy w/fetal loss and retention of 1 fetus, delivered with or
without mention of antepartum condition
Multiple gestation, triplet pregnancy, w/fetal loss and retention of one or more fetus (es),
delivered with or without mention of antepartum condition
Multiple gestation, quadruplet pregnancy, w/fetal loss and retention of 1 or more
fetus(es), delivered with or without mention of antepartum condition
Multiple gestation, other multiple pregnancy, w/fetal loss and retention of 1 or more
fetus(es), delivered with or without mention of antepartum condition
Multiple gestation following (elective) fetal reduction, delivered without mention of
antepartum condition
Multiple gestation, other specified multiple gestation, delivered with or without mention of
antepartum condition
Multiple gestation, unspecified multiple gestation, delivered with or without mention of
antepartum condition
Unstable lie, delivered, w/ or w/out mention of antepartum condition
Multiple gestation w/malpresentation of 1 fetus or more, delivered, w/ or w/out mention of
antepartum condition
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655.01 Central nervous system malformation in fetus, delivered, w/ or w/o mention of antepartum
condition
655.11 Chromosomal abnormality in fetus, delivered w/ or w/o mention of antepartum condition
655.31 Suspected damage to fetus from viral disease in the mother, delivered w/ or w/o mention
of antepartum condition
655.41 Suspected damage to fetus from other disease in the mother, delivered w/ or w/o mention
of antepartum condition
655.51 Suspected damage to fetus from drugs, delivered w/ or w/o mention of antepartum
condition
655.61 Suspected damage to fetus from radiation, delivered w/ or w/o mention of antepartum
condition
655.80 Other known or suspected fetal abnormality, not elsewhere specified
656.01 Fetal-maternal hemorrhage, delivered, w/ or w/o mention of antepartum condition
656.11 Rhesus isoimmunization, delivered, w/ or w/o mention of antepartum condition
656.21 Isoimmunization from other and unspecified blood-group incompatibility, delivered, w/ or
w/o mention of antepartum condition
656.31 Fetal distress, delivered, w/ or w/o mention of antepartum condition
656.41 Intrauterine death, delivered, w/ or w/o mention of antepartum condition
656.51 Poor fetal growth, delivered, w/ or w/o mention of antepartum condition
657.01 Polyhydramnios, delivered w/ or w/o mention of antepartum condition
658.01 Oligohydramnios, delivered w/ or w/o mention of antepartum condition
658.11 Premature rupture of membranes, delivered w/ or w/o mention of antepartum condition
658.21 Delayed delivery after spontaneous or unspecified rupture of membranes, delivered w/ or
w/o mention of antepartum condition
659.71 Abnormality in fetal heart rate or rhythm, delivered, w/ or w/o mention of antepartum
condition
663.50 Vasa previa complicating labor and delivery, unspecified as to episode of care or not
applicable
663.51 Vasa previa complicating labor and delivery, delivered, with or without mention of
antepartum condition
663.53 Vasa previa complicating labor and delivery, antepartum condition or complication
V08
Asymptomatic human immunodeficiency virus [HIV] infection virus
V23.5 Pregnancy with other poor reproductive history; Pregnancy with history of stillbirth or
neonatal death
V27.1 Single stillborn
Note: The list of exclusions above is the exclusions listed by The Joint Commission. These are
the only exclusions that should be used for this measure. If a patient’s diagnosis was not coded,
there must be explicit language in the chart noting the diagnosis (no interpretation or
extrapolation is allowed).
Numerator: Number of cases included in the denominator (either from full case reporting or a
sufficient sample) that delivered their newborns electively.
Elective delivery, for purposes of this measure, include the following:

Medical induction of labor as defined by the following ICD-9-CM procedure codes:




73.01 (Induction by labor by artificial rupture of membranes)
73.1 (Other surgical induction of labor)
73.4 (Medical induction of labor)
Cesarean section as defined by the following ICD-9-CM procedure codes, while not in Active
Labor or experiencing Spontaneous Rupture of Membranes:



74.0 (Classical cesarean section)
74.1 (Low cervical cesarean section)
74.2 (Extraperitoneal cesarean section)
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Section 4: CACs
74.4 (Cesarean section of other specified type)
74.99 (Other cesarean section of unspecified type)
Active Labor: Documentation that the patient was in active labor with regular uterine contractions
with cervical change before medical induction and/or cesarean section.
Spontaneous Rupture of Membrane: Documentation that the patient had spontaneous rupture of
membranes (SROM) before medical induction and/or cesarean section.
Report this value in Q3.
Important Note: Normal Deliveries-2 and Normal Deliveries- are both process measures. Hospitals with a
sufficient sample size (as defined in endnote 19 in the survey document itself), can randomly sample for
the denominator of each indicator, and measure and report adherence based on that sample. Most likely
the numerator criteria for these two measures will require medical chart review, if these specific data are
not already extracted or coded consistently for other purposes.
Normal Deliveries Process Measures Specifications: Survey
p.41
Normal Deliveries-2: Newborn Bilirubin Screening Prior to Discharge
Source: Providence Health
Denominator: Eligible cases include all normal newborns born at or beyond 35 completed
weeks gestation that were delivered in the facility during the reporting period (all inborns) with
Excluded Populations removed.
Excluded Populations:
Exclude any cases:
 admitted to the NICU; or
 with parental refusal to test; or
 newborn died prior to discharge
Numerator: Number of eligible cases included in the denominator who have a serum or
transcutaneous bilirubin screen prior to discharge to identify risk of hyperbilirubinemia according
to the Bhutani Nomogram
See:
American Academy of Pediatrics Clinical Practice Guidelines: Management of Hyperbilirubinemia
in the Newborn Infant 35 or More Weeks of Gestation.
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/1/297
Tip: To view any Figure in the reference, click on it to open, then again to enlarge.
Normal Deliveries-3: Appropriate DVT Prophylaxis in Women Undergoing Cesarean
Delivery
Source: National Quality Forum (PN-006-07)
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Denominator: Eligible cases include all women undergoing cesarean delivery during the
reporting period.
Include cases with one of the following ICD-9-CM codes (MS-DRG*):
 765 (formerly 370): Cesarean section w CC
 766 (formerly 371): Cesarean section w/o CC
*For hospitals that do not use MS-DRGs, please see the FAQ section at the end of this document for a list of alternative
administrative codes that should be used for identifying cases.
Excluded Populations:
No exclusions.
Numerator: Number of eligible cases included in denominator who received either fractionated or
unfractionated heparin or pneumatic compression devices prior to surgery.
Normal Deliveries Frequently Asked Questions (FAQs)
1. Our hospital reports the perinatal core measures to The Joint Commission. Can we use
The Joint Commission’s sampling methodology for reporting on the Elective Delivery
measure, in lieu of the sampling methodology outlined by Leapfrog?
Yes. Hospitals that report to The Joint Commission (TJC) can use the sampling methodology
used by TJC, in place of the sampling methodology described by Leapfrog.
2. Our hospital is designated as a critical access hospital (CAH) and we do not use MS-DRGs
for reimbursement purposes. What alternative coding specifications are available to
identify appropriate cases for Normal Deliveries-3 (DVT prophylaxis for c-section)?
For the denominator, count all cases with one of the delivery diagnosis codes listed below AND
one of the c-section procedure codes listed below.
Delivery Diagnosis ICD-9 Codes:
640.x1 647.x1 654.x1 658.30
641.x1 647.x2 654.x2 658.40
642.x1 648.x1 655.x1 659.x0 (except 659.40)
642.x2 648.x2 656.x1 659.x1
643.x1 649.x1 656.30 660.x0
644.21 649.x2 656.40 660.x1
645.x1 650
657.01 661.x0
646.00 651.x1 658.x1 661.x1
646.x1 652.x1 658.10 662.x0
646.x2 653.x1 658.20 662.x1
663.x0
663.x1
664.x0
664.x1
665.x0
665.x1
665.x2
666.x2
667.x2
668.x0
668.x1
668.x2
669.x0
669.x1
669.x2
670.02
671.x1
671.x2
672.02
673.x1
673.x2
674.x1
674.x2
675.x1
675.x2
676.x1
676.x2
678.01
678.11
679.00
679.01
679.02
679.11
679.12
Caesarean Section ICD-9 Procedure Codes:
74.0 Classical cesarean section
74.1 Low cervical cesarean section
74.2 Extraperitoneal cesarean section
74.4 Cesarean section of other specified type
74.99 Other cesarean section of unspecified type
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Normal Deliveries Scoring Algorithm
Measure
Elective Delivery Prior
to 39 Completed
Weeks Gestation
Newborn Bilirubin
Screening Prior to
Discharge
Appropriate Deep
Venous Thrombosis
Prophylaxis in Women
Undergoing Cesarean
Delivery
Type of
Measure
Outcome
Process
Process
Minimum Sample Size for
Scoring
10 mothers that delivered
singletons at or past 37
completed weeks gestation at
the hospital during the
reporting period
(answer to Q2 >= 10)
10 normal newborns born at
or beyond 35 completed
weeks gestation delivered at
the hospital during the
reporting period
(answer to Q4b >= 10)
10 women undergoing
cesarean section at the
hospital during the reporting
period
(answer to Q5b >= 10)
Desired
Direction
Score on Measure
Lower
Less than or equal
to 5.0% (+1 point);
greater than 5.0%
(+0 point)
Higher
Greater than or
equal to 80.0% (+1
point); less than
80.0% (+0 point)
Higher
Greater than or
equal to 80.0% (+1
point); less than
80.0% (+0 point)
The number of points a hospital earns on the above measures will determine which category a hospital is
placed:
Score
Fully meets standards (4 filled
bars)
Substantial progress (3 filled bars)
Some progress (2 filled bars)
Point Requirements
2 or more points earned, with at least 1 point from the outcome
measure
2 points earned from the process measures –or- 1 point earned from
the outcome measure
1 point earned from a process measure
Willing to report (1 filled bar)
0 points earned
Declined to respond
The hospital did not respond to the questions in this section of the
survey, or the hospital did not meet the minimum sample size for the
outcome measure and chose not to report on the two process
measures, or the hospital was asked to complete the survey but has
not submitted one.
Does Not Apply
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The hospital does not meet the minimum sample size for at least two
of the measures.
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Normal Deliveries Section Complete
Save your Responses!
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Section 5: IPS
Section 5: 2011 ICU Physician Staffing (IPS) Leap
What’s New in the 2011 Survey
1. The opportunity for hospitals to indicate a commitment date for fully implementing Leapfrog’s
standards for IPS has been removed from the survey. Leapfrog has been asking for ten years for
hospitals to implement the IPS Leap and publicly reporting future commitments is no longer
appropriate. The scoring algorithms for IPS have been updated to reflect this change.
Change Summary since Release
None. If substantive changes are made to this section of the survey after release on April 1, they will be
documented in this Change Summary section.
December 13, 2011
Updated the IPS scoring algorithm to correct an error. For “Some Progress”, a ‘yes’ answer to question #9
demonstrates that some patients in the ICU are being managed or co-managed by an intensivist.
IPS Frequently Asked Questions (FAQs)
1. Are the standards applicable only to tertiary-care hospitals?
No. The standards apply to all urban hospitals operating adult or pediatric general medical and/or
surgical ICUs and neuro ICUs.
2. Is there any empirical basis for specifying a minimum annual number of days of ICU
experience for each Board-eligible physician providing ICU care?
No. Accordingly, if it is added to the Leapfrog standard in the future, it will be based on newly
published research and expert advice.
3. Can hospitalists be counted as intensivists?
No.
4. If our hospital requires that ICU pages are answered within five minutes and therefore
does not track responses to pages, how should we report our compliance on this part of
the standard?
To meet the Leapfrog standard, hospitals must affirm to the public that they meet it. If your
hospital requires that pages be answered within five minutes and has documentation that they
are, then you should indicate that your hospital meets the standard. If your hospital requires that
pages are answered within five minutes and you don’t know whether they are or are not, then you
should not indicate that your hospital meets the standard.
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5. Does The Leapfrog Group specify standards for second tier calls (e.g., the initial call to a
physician is not answered within 5 minutes. What is the next step)?
No. We do not intend to reach this level of detail in our specifications, absent a compelling case
that the gain would offset its added complexity.
6. What training is required in order to be eligible for Critical Care Medicine (CCM)
certification?
A physician must complete residency in Medicine, Surgery, or Anesthesia and then a one- or twoyear fellowship in critical care medicine. During that year, s/he must spend at least nine months in
the ICU. The two-year fellowships generally include research time. Some Medicine residents are
certified in critical care through pulmonary subspecialty training where they meet the above
requirements during their three-year pulmonary training. New in 2008: Neurologists and
neurosurgeons who have been certified as neuro-intensivists are also considered to meet the
standard when working in a neuro-ICU.
7.
If it were a national priority, could enough intensivists be provided (or mobilized from
ambulatory care) for urban hospitals within the next 4 years?
If it were a national priority, it is possible. Critical care fellowship training extends for either one or
two years. History suggests that physicians’ choice of specialty is sensitive to the job market.
Further, it is currently estimated that less than 50% of the work time of the existing pool of
intensivists is devoted to ICU care. In addition, recently published findings in the peer-reviewed
literature (B. Rosenfeld, et al, Critical Care Medicine, Fall 2000) indicate that advanced
telemedicine could be used to offset local constraints in available intensivists and telemedicine for
intensivists has been incorporated into the standard.
8.
How will The Leapfrog Group address the shortage of intensivists?
We will (1) create demand via our standard; (2) encourage specialty boards and the Association
of Academic Medical Colleges to convey the anticipated new demand; (3) sensitize federal
officials who set physician training and loan forgiveness priorities; (4) support ICU consolidation
when it makes sense; and (5) encourage hospitals that are successfully using advanced
telemedicine to leverage intensivists across multiple ICUs to share their results and learnings with
other hospitals.
In 2003, The Leapfrog Group broadened the definition of ‘intensivist’ to include doctors who
clearly have intensivist qualifications:
 Because sub-specialty certification is not offered in emergency medicine, emergency
medicine physicians are considered certified in critical care if they are board-certified in
emergency medicine and have completed a critical care fellowship at an ACEP-accredited
program.
 Physicians who have finished their fellowship in Critical Care Medicine, but have not yet
obtained board certification are considered “Certified in Critical Care Medicine” for up to three
years after completion of the fellowship. This provides the physician an adequate window to
take her/his boards and re-take if necessary.
 On an interim basis, two other categories of physicians are considered by Leapfrog to be
“certified in Critical Care Medicine”:
 Physicians who completed training prior to availability of subspecialty certification in
critical care in their specialty (1987 for Medicine, Anesthesiology, Pediatrics and
Surgery), who are board-certified in one of these four specialties, and who have
provided at least six weeks of full-time ICU care annually since 1987. (The weeks
need not be consecutive weeks).
 Other physicians who have completed training programs required for certification in
critical care medicine.
Note: Physicians who have let their board certification lapse are not considered to be “Certified in
Critical Care Medicine”.
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9.
Section 5: IPS
Won't it degrade the meaning of meeting the Leapfrog ICU leap to expand the definition of
an intensivist to include physicians certified in emergency medicine who have completed
a critical care fellowship and to physicians who trained prior to 1987 and regularly practice
full time critical care for a significant period?
Though this change also reflects our sensitivity to the intensivist shortage, our decision to provide
interim credit for these physicians is based on justice and patient benefit. Board certified
emergency medicine physicians cannot become certified in critical care medicine (though their
board is working on this) despite completing a fellowship in critical care.
Inclusion of physicians who completed their training in surgery, medicine or anesthesiology prior
to 1987 when critical care certification first become available only applies to physicians who are
board certified and have provided at least 6 weeks annually of full time ICU care since 1987. It
includes a significant number of critical care fellowship directors who trained prior to 1987 and
who continue to train other critical care physicians. Our expert advisory panel (comprised
primarily of physicians who publish research on ICU performance) elected to provide interim
credit to physicians meeting this specification. The 6 week threshold was selected based on a
consensus perception of a reasonable minimum of ongoing full time ICU experience.
To protect patients from under-qualified physicians, the advisory panel worded the interim
standard conservatively. It likely applies to very few physicians. As the supply of intensivists
builds, credit will eventually be limited to board certified critical care specialists. The Leapfrog
Group strives to make its recommendations based on empirical evidence. When we lack such
evidence, we take a common sense approach that builds on the judgment of clinicians most
familiar with available scientific evidence and aims at serving patients best.
10. Are we expected to conduct an audit to verify that high-urgency pages are returned within
5 minutes, and are there definitions for what constitutes high and low urgency pages?
You should have some quantitative basis for saying that pages are returned within 5 minutes at
least 90% of the time. You could study a sample, or could use the tracking mechanism built in to
the paging system, if one exists. The basis for responding affirmatively should be more than just
peoples’ perceptions of response time.
You don’t have to focus only on high urgency pages – but some paging systems can make this
differentiation and, in these instances, low urgency pages can be carved out of the analysis of
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.
11. Can you clarify how to handle situations where the ICU standard is met some but not all
of the time?
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If the ICU standard is not met at least 8 hours a day, 7 days a week (if you responded no to
Question 3), hospitals have the opportunity to get partial credit for having intensivists on-site at
least some time during the week, or having telemedicine in place that meets the specified criteria
for telemedicine. If the number of hours varies from week to week, hospitals should respond with
the number of hours per week that the ICU standard is usually met.
12. What are the standards for staffing a neuro ICU? Who qualifies as a “neurointensivist”?
To fully meet the IPS Leap, neuro ICUs must now meet the staffing standards that have been
previously set for adult or pediatric general medical and/or surgical ICUs. Patients in a neuro ICU
must be managed or co-managed by “neurointensivists” or critical care intensivists who are
ordinarily present in the ICU (on-site, or via telemedicine that meets Leapfrog specifications)
during daytime hours a minimum of 8 hours per day, 7 days per week, and during this time
provide clinical care exclusively in the ICU. When not present, “neurointensivists” or critical care
intensivists must return more than 95% of ICU pages within 5 minutes and can rely on a
physician or FCCS-certified non-physician “effector” who is in the hospital and able to reach ICU
patients within 5 minutes in more than 95% of cases.
“Neurointensivists” are classified as neurologists and neurological surgeons who are boardcertified in their primary specialty and who have completed a UCNS-certified fellowship training
program in neurocritical care, or a physician who is board certified in neurocritical care. Existing
physicians must obtain certification using the grandfathering process established by UNCS to be
considered a neurointensivist. This new category of intensivists applies only to neuro ICUs.
13. How should intensivisits trained in critical medicine in a foreign country be treated for
purposes of meeting the ICU Physician Staffing (IPS) Leap? While they offer excellent
training, many foreign countries do not offer specific critical care board certifications.
Foreign trained physicians who were certified as intensivists in the country in which they trained,
also count as intensivists for the purposes of the ICU Physician staffing (IPS) Leap.
IPS Scoring Algorithm
Fully meets standards:
1. All patients in adult and pediatric general medical and surgical ICU(s) and neuro ICUs are
managed or co-managed by one or more physicians who are certified in critical care medicine
(intensivists) (answered “Yes” to # 2); and
2. One or more intensivist(s) is/are present in each ICU during daytime hours on-site for at least 8
hours per day, 7 days per week or via telemedicine 24 hours per day, 7 days per week, and
provide(s) clinical care exclusively in this ICU during these hours (answered “Yes” to #3); and
3. When intensivists are not present (on-site or via telemedicine) in these ICUs, one of them returns
more than 95% of pages from these units within five minutes. (answered “Yes” to #4); and
4. When an intensivist is not present (on-site or via telemedicine) in the ICU, another physician,
physician assistant, nurse practitioner or FCCS-certified nurse “effector” is on-site at the hospital
and able to reach ICU patients within five minutes in more than 95% of the cases (answered
“Yes” to #5).
When telemedicine is employed as a substitute for on-site time, it must meet the ten requirements
(see endnote #29) including some on-site intensivist time to manage the ICU patients’ admission,
discharge, and care planning.
Substantial progress:
1. All patients in adult/pediatric medical ICU(s) and neuro ICUs are managed or co-managed by one
or more physicians who are certified in critical care medicine (intensivists) when those physicians
are present, whether on-site or via telemedicine (answered “Yes” to #2); and
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2. The hospital has a board-approved budget that is adequate to meet the IPS commitment
(answered “Yes” to #10); and
3. The hospital has implemented any one or more of the following practices:
a. Intensivists are present and manage or co-manage all patients in all ICUs on-site at least
8 hours per day, 4 days per week (answered “Yes” to #6 );
b. Intensivists are present and manage or co-manage all patients in all ICUs via
telemedicine 24 hours per day, 7 days per week (answered “Yes” to #7) with on-site daily
care planning at least 4 days per week (answered “Yes” to #8); use of telemedicine
requires that additional Leapfrog telemedicine specifications are met; or
c. Clinical pharmacists make daily rounds on adult medical/surgical and neuro ICU patients
(answered “Yes” to #11).
and
4. An intensivist:
a. leads daily, multi-disciplinary team rounds on-site (answered “Yes” to #12), or
b. makes admission and discharge decisions when on-site (answered “Yes” to #13).
Substantial progress alternative for Hospitals Classified as Rural:
1. All patients in adult/pediatric medical ICU(s) and neuro ICUs are managed or co-managed by one
or more physicians who are certified in critical care medicine (intensivists) when those physicians
are present, whether on-site or via telemedicine (answered “Yes” to #2); and
2. Intensivists are present and manage or co-manage all patients in all ICUs via telemedicine that is
functional 24 hours per day, 7 days per week with onsite care planning done by an intensivist,
hospitalist, anesthesiologist, or a physician trained in emergency medicine (answered “Yes” to
#7); use of telemedicine requires that additional Leapfrog telemedicine specifications are met.
Some progress:
1. The hospital has a board-approved budget that is adequate to meet the IPS commitment
(answered “Yes” to #10); and
2. Some patients in the ICU(s) are managed or co-managed by an intensivist when present on-site
or via telemedicine (answered “Yes” to # 6 or “yes” to #7 or #8 or #9). Use of telemedicine
requires that additional Leapfrog telemedicine specifications are met.
Willing to report:
The hospital responded to all the Leapfrog survey questions, but it does not yet meet the criteria for
Some progress.
Declined to respond:
The hospital did not respond to this section of the survey, or the hospital was asked to complete the
survey but has not submitted one.
Does Not Apply:
The hospital does not operate an adult or pediatric general medical or surgical intensive care unit or a
neuro intensive care unit.
Response not required:
Hospital not targeted for reporting on this Leap.
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Section 6: NQF Safe Practices
Section 6: 2011 Leapfrog Safe Practices Score (SPS)
What’s New in the 2011 Survey
1. Hospitals will indicate as part of Safe Practice #9 if they have current Magnet status designation,
as determined by the American Nurses Credentialing Center (ANCC). If a hospital does indicate
they have current Magnet status, they will automatically earn full credit for Safe Practice #9
without needing to fill-in any of the checkboxes.
Change Summary since Release
None. If substantive changes are made to this section of the survey after release on April 1, they will be
documented in this Change Summary section.
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SPS Frequently Asked Questions (FAQs)
Also see the more detailed FAQs specific to the SPS section 6 of the survey at the online survey
home page.
1. Why was the NQF Safe Practices report used for development and revisions of the
survey?
The initial NQF Report and the first accompanying set of Safe Practices provided a
comprehensive and accessible document addressing specific practices to improve patient safety
and healthcare quality. Since that initial report, a Maintenance Committee was established by the
NQF and a revised set of Safe Practices were endorsed in 2006, 2009, and 2010. The 2010
report details 34 Safe Practices that should be universally implemented in clinical care to reduce
the risk of harm to patents. The practices address the first three “leaps” of the Leapfrog Group
and continue to be assessed in separate survey sections. A subset of the remaining 31 practices
are now addressed in the SPS survey section.
The initial and subsequent NQF reports were developed using a consensus process by a
committee representing some of the foremost thought leaders and stakeholders in patient safety.
The initial committee and the maintenance committee included members of patient and consumer
groups, healthcare purchasers, health plans, healthcare providers, and research and quality
improvement organizations. In accordance with the National Technology Transfer Advancement
Act of 1995 (P.L. 104-113), the federal government may use the information in the NQF report for
standardization purposes. As such, the initial survey was designed to be based on and limited to
the content, scope, and evidence provided by the NQF Safe Practices for Better Healthcare: A
Consensus Report of May 2003; likewise, the new revised survey of safe practices is consistent
with the content of the 2010 Update released by NQF in April in 2010.
2. How was the NQF Safe Practices survey section developed?
This updated survey section was developed by the Texas Medical Institute of Technology (TMIT),
a not-for-profit medical innovation research organization, based on advice from a 10 member
Senior Advisory Board of patient safety and performance improvement national thought leaders
chaired by Dr. Charles Denham. The Senior Advisory Board worked with input from more than
260 subject matter experts (SMEs) who have strong command of the medical literature and deep
understanding of the best practices targeting the problem areas addressed in the NQF report.
The SME frontline expertise includes the domains of medication management, ICU, surgery,
healthcare law, administration, human factors, reliability science, culture and systems
psychology. The SMEs contributed to the NQF practice and evidence assessment. They also
participated in the development of revised relative weights for each practice for 2007. In addition,
several hospital industry associations and numerous individual hospital representatives provided
input on the survey content. This input was complemented by research through the TMIT
Research Test Bed addressing more than 300 hospitals submitting to the prior Leapfrog surveys.
A number of our Leapfrog experts were former clinicians and administrative contributors to the
original NQF report and also served on the maintenance committee. For 2008, Leapfrog reduced
the number and length of the survey, allowing hospitals to focus on the most heavily weighted
practices for the survey.
3. After submission of this portion of the survey, how will a hospital be scored?
See the detailed scoring algorithm for details on how the Safe Practices section will be scored.
The scoring algorithm can be accessed from the home page of the survey.
4. How much time and effort is required to complete this part of the survey?
The time and effort it will take a hospital to complete this section of the survey will vary based on
a number of factors, including the number of persons in the organization involved in answering
this section of the survey and accessibility to needed information. Leapfrog anticipates the level of
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Section 6: NQF Safe Practices
burden to complete this section of the survey has been reduced by focusing on just 17 of the 31
Safe Practices.
5. What is the most efficient approach to complete the survey?
The experience from Leapfrog Pilot hospitals and the more than 50 TMIT Research Test Bed
hospitals as well as research with more than 300 original hospital submitters to this Leap over
2005 and 2006 has enabled TMIT to refine support information for submitters, which is available
in more detail through web links from the survey and Leapfrog Group Web sites. Briefly,
recommended steps are as follows:
 Prepare: Obtain copies of the NQF report of 2010 (see link on the ‘Download Survey
Materials’ page of the online survey for ordering information). Hardcopy versions of the
report, the survey, the Leapfrog Fact Sheet, and the survey FAQs should be reviewed by the
person responsible for submission. That person should decide who should participate on their
team to assist in collection of the documentation for assessment.
 Plan: We suggest that a team be formed that might just be a couple of individuals in some
hospitals or a much larger group for larger organizations. That team should be briefed,
assigned duties to help capture the key information necessary for submission.
 Collect: Key documentation should be collected to support answering the survey. It will be
helpful to archive it for future reference when the survey is updated or re-submitted by the
hospital.
 Assess: When all of the supporting documents are assembled, it is recommended that a
preliminary score be generated. A meeting with the CEO and/or responsible leadership team
should be undertaken and decisions should be made as to how the score might be improved
over the course of the year. Hospitals should update their answers online as they achieve the
requirements in the survey.
 Submit: The survey should be submitted online per the instructions provided on the survey
site.
6. The NQF Safe Practices for Better Healthcare 2010 Update: A Consensus Report was
released in April of 2010. How does the survey deal with a report that is lacking detailed
measures?
The NQF report is an excellent publication; however it is a set of standards and implementation
suggestions; it is not an endorsed measure set. The measurement of adoption of the endorsed
set of standards is done through this survey; however the design of the survey is closely aligned
with the implementation guidance in the report.
In order to create an effective survey instrument and relative weighting system, the following
principles were followed.



4 A Framework: The 4 A Adoption Framework (see below) was designed to measure
progress on the problem being targeted by the practices; over time the questions in the
survey have evolved based on experience and research and now on the new set of Safe
Practices. The 4 A Adoption Framework is still in place, but this set of survey questions is
more specific than the survey designed for the first report, where more latitude was given to
hospitals in terms of implementation strategies and the ability to make commitments for
implementation.
Focus on Practices: The evidence, practices, and implementation details have gone
through a complete and comprehensive review by the NQF Maintenance Committee, and as
a result the new report is more actionable than the initial report. The survey is still designed
for a mid-level manager of a frontline community hospital to complete.
Systematic Application of 4 A Adoption Framework: A framework defining dimensions of
progress in patient safety of Awareness, Accountability, Ability, and Action (4 A’s or 4 A
Framework – C.Denham) was used in formulation of survey questions. As a result of the
changes to the practices, measures are more clearly aimed at specific processes and
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
Section 6: NQF Safe Practices
outcomes. Partial credit is still available for having completed some, but not all of the key
strategies for implementing the Safe Practices.
Define practices as readily available to mid level manager at frontline community
hospital: The Medical Advisory Board and Subject Matter Experts were asked to focus on
the problem cited in the NQF report and emphasize the impact of best practices “currently
and readily available to a mid level manager at a frontline urban community hospital”
on the problem including, but not limited to, the specifications and implementation
approaches cited. This allowed the weighting, survey, and ranking system to be normalized
to the most representative case of hospitals across the country. It also limited confusion
around currently published studies and opened the field of review to the medical literature,
Internet resources, and readily available expert opinion from quality improvement groups.
This did not violate the principle of operating within the scope of the NQF report.
7. Given this section of the survey is now shorter—will we still get partial credit? Can we still
get credit for commitments?
This section of the survey has been reduced, it now reflects on only 17 of the remaining 31 safe
practices. We have maintained the same structure of Awareness, Accountability, Ability and
Action in this new version. It is also still possible to get partial credit, but we no longer give credit
for commitments. We have heard hospitals concerns about the veracity of their colleagues in
completing the survey. In this year’s SPS section you will note that most of the questions are
written to include documentation of efforts made, which will allow for audits by individual plans,
other purchasers, or pay-for-performance programs.
8. Why is each practice area is broken down into the 4 A’ Framework: Awareness,
Accountability, Ability, and Action?
Organizations must have awareness of performance gaps and through direct measurement they
must be aware of their own performance gaps. Accountability of leadership to improve
performance is critical to accelerate innovation adoption. An organization may be aware, and the
leadership accountable, however if the staff do not have the ability to employ new practices
meaning the capacity and resources to do so success is at risk. Finally, action must be taken with
discipline over time that is measurable both by process measures and outcome measures that
clearly tie to closing performance gaps. (The 4 A Adoption Framework was developed by Dr.
Denham of TMIT published in 2001).
 Awareness: Most of the NQF Safe Practices are defined with a safety objective addressing
the nature of a preventable adverse event. The cause of these adverse events are fairly well
understood and well known. Each NQF Practice was treated individually depending on how
well understood THE performance opportunities are and how well a hospital can address
their – OUR performance opportunities. Although all questions were developed custom
designed to the safety objective/practice, a standardized guide was developed to assist in the
process.
 Accountability: Accountability addresses direct accountability of the appropriate leaders to
the adverse event area.
 Ability: A graduated set of investment levels were used ranging from investment in
education, skill development, allocated human resources, and line item budget allocations.
These were adjusted in a safety objective/practice specific way.
 Actions: Action levels were tied to NQF language well as they could be. Performance
Improvement programs and projects were tied to actions as they are recognized as critical to
sustained performance. Where possible, the actions were tied to those promulgated by The
Joint Commission.
9. This part of the survey places significant emphasis on Performance Improvement
Projects/ Programs. Why?
The greatest sustained improvement and cost savings have been achieved by hospitals that have
undertaken formal Performance Improvement Programs with measurement and process
improvement features that then tie to explicit procedures and protocols (as cited in some but not
all of the NQF Safe Practices).
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10. There are many types of Performance Improvement Programs and project methodologies.
What elements are required to satisfy the requirements for credit for such programs or
projects?
Generally, five elements must be present (and are typically present in most such programs or
projects):
 Education: Staff and caregivers should be educated regarding the nature of the adverse
events being targeted and the impact of better or best practices.
 Skill Development: Staff and caregivers should be briefed and equipped to have the skills
necessary to undertake a performance improvement project.
 Measurement: Process measures or outcome measures should be assessed and tracked.
 Process Improvement: A feedback process improvement component should be employed
to improve processes, test the change, and then provide feedback through measurement to
improve outcomes.
 Reporting: Results of performance improvement projects or programs should be reported to
the administrative leadership and caregivers.
However, it is very important to review the NQF Report for more detailed specifics on
implementation strategies that are mentioned for each Safe Practice.
11. What Guiding Principles were followed to design the relative Weighting System? Are the
weights the same as previous surveys?
Below we describe how the weights (which are still applied) were developed.
 Enterprise-wide Systems & Process Areas Prioritized: In preparation for the formal voting
process all Advisory Board members were presented with the concept of allocating weighting
to enterprise-wide systems focus areas and enterprise-wide process focus areas as a first
step, followed by allocating weight to care setting-specific areas. All were in agreement and
this process was followed. Weighting was made to an agreed set of enterprise-wide
problems/practices and the balance of the points allocated by a relative weighting vote.
 Neutralize NQF Report Limitations: As with the survey question design process, the
limitations of the NQF report were neutralized by emphasis on the problem cited by the NQF
rather than the practices and by employment of the 4 A framework of patient safety progress.
 Focus on Safety Objectives (cited by NQF) and Practices: The Safety Objectives and
cited adverse events addressed in the NQF report were entirely satisfactory and the “right
list” as evaluated by the Medical Advisory Board.
 Emphasize Impact (Frequency x Severity x Practice Impact): The Advisory Board was
provided with resources of prior incidence studies (Utah-Colorado and others) and weighting
systems used by organizations such as the Veterans Healthcare Administration. The
common approach patient safety researchers use is that factor frequency (prevalence),
severity of the problem, and impact of readily available practices. A global relative weighting
approach was determined to be the most appropriate for this survey.
 Use Transparent Multi-round Multi-voting: A rapid cycle transparent multi-round voting
method was used to allow the Advisory Board to vote, discuss their votes, review individual
practices and problems, evaluate point spread across voters and across voting rounds. All
practices were individually reviewed and discussed before and after each voting round. Only
two voting rounds were required for consensus.
Yes, the weights used for each Safe Practice in this year’s Safe Practices section match the
weights established by the Advisory Board in 2007. The only change being the number of
practices that Leapfrog asks hospitals to report on. Starting with the 2009 survey, a weight was
assigned to the Prevention of Catheter Associated Urinary Tract Infection Safe Practice.
12. How frequently should my hospital respond to this survey?
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Throughout the year, hospitals should resubmit their responses if and when their status changes
with regard to any of the questions. This will ensure that hospitals’ most current status is
accurately reported to The Leapfrog Group and in the results they publish.
The Leapfrog Group plans to revise its recommended patient safety practices and the hospital
survey on a yearly schedule designed to coincide with most employers’ health care benefits
enrollment periods. We are committed to depicting your current patient safety improvement
efforts accurately to consumer and purchasers, maintaining current information, and keeping our
patient safety recommendations up to date based on continuous input from national experts.
Annual survey revisions are planned for release each April. All publicly reported results from the
prior survey cycle will be replaced in early July with results based on new surveys submitted
through June 30. Public results will be updated monthly thereafter, approximately the second
business day of each month, based on surveys (re)submitted through the end of the previous
month.
13. How frequently will the survey be updated?
The survey will be updated every year. Future updates will include more detailed process
measures and outcome measures designed to reflect the evolution in best practices and literature
support for action in patient safety.
14. What is required of a hospital to attain the “four bar” top level recognition for the NQF
Safe Practices section of the survey?
To attain top level recognition, a hospital must rank in the top performance category, based on
quartile cutpoints established from surveys submitted as of June 30, 2011.
Also see the more detailed FAQs specific to the SPS section 6 of the survey at the online survey
home page.
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SPS Scoring Algorithm
The Leapfrog Safe Practices Score (SPS) measures hospitals’ progress on 17 of the National Quality
Forum Safe Practice areas. Each practice area is assigned an individual weight, which is factored into the
overall score. Hospitals are then put into performance categories based on their relative progress out of
the total number of possible points.
A hospital’s results are publicly released and displayed on the Leapfrog Group Web site in one of five
categories:
 Fully meets standards (4 filled bars) means the hospital is in the top performance category for
Overall Points across all Safe Practices that apply to the hospital.
 Substantial progress (3 filled bars) means the hospital is above the midpoint (median), but not
in the top performance category, for Overall Points across all Safe Practices that apply to the
hospital.
 Some progress (2 filled bars) means the hospital is below midpoint (median), but not in the
lowest performance category, for Overall Points across all Safe Practices that apply to the
hospital.
 Willing to report (1 filled bar) means the hospital is in the bottom performance category for
Overall Points.
 Declined to respond means the hospital did not respond to this section of the survey, or the
hospital was asked to complete the survey but has not submitted one.
Within each Safe Practice/Element, each checkbox has the same value, equal to the total points assigned
to that Practice/Element divided by the number of checkboxes in that Practice/Element.
Where a hospital’s responses indicate that a Safe Practice does not apply, the total available points will
be less than the maximum 737 points. In these cases, total points earned for checked items is rebalanced
(upward) by the ratio of maximum points to total available points to put the hospital on equal footing with
other hospitals to which those NA-items do apply.
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Scoring and ranking details are described below.
1. Maximum Points : Each of the 17 Safe Practices has a number of points, or Maximum Points, based
on the relative impact of the safe practice.. Maximum Points for all Practices total 737. See below for
a list of Safe Practices/Elements and their respective Maximum Point values.
Weighting
(pts)
Safe Practice
1
2
3
4
5
6
9
12
14
15
17
19
21
23
25
28
29
Leadership Structures and Systems
Culture Measurement for Performance
Teamwork Training and Skill Building
Identification and Mitigation of Risks and Hazards
Informed Consent
Life Sustaining Treatment
Nursing Workforcea
Communication of Critical Information
Labeling of Diagnostic Studies
Discharge Systems
Medication Reconciliation
Hand Hygiene
Central Venous Catheter Related Bloodstream Infection Preventionb
Prevention of Aspiration and Ventilator Associated Pneumoniab
Catheter Associated Urinary Tract Infection Prevention c
DVT/VTE Preventionc
Anticoagulation Therapyc
GRAND TOTAL
120
20
40
120
4
4
100
84
15
25
35
30
30
20
30
25
35
737
a Hospitals
indicating in Safe Practice #9 that they have current Magnet status designation, as determined by the
American Nurses Credentialing Center (ANCC), will receive full points for this Safe Practice.
b If this Safe Practice does not apply at your hospital, you can indicate so at the beginning of this Safe-Practice
section. To submit this section of the survey, this Safe Practice needs to be completed, even if only to indicate not
applicable to your hospital.
c This Safe Practice does not apply to children’s hospitals but must be “completed”. Go to the practice and click
“Finished”. Any responses will be ignored.
2. Point Values per Checkbox: Within a Practice or Element, each question has an equal point value,
computed as the Maximum Points for that Practice/Element divided by the number of checkboxes
within that Practice/Element.
3. Available Points: Some Practices might not apply to a hospital, in which case total Available Points
will be 0 for that Practice. (Any one or both of two Safe Practices -- # 21 and 23 – might not apply to a
hospital. Safe Practices #25, 28 and 29 do not apply to children’s hospitals.) If so, the total Available
Points across all Practices will not include the Maximum Points for those Practices. The online survey
will not allow any checkboxes to be marked in those Practices and scoring for those Practices will be
marked NA in Leapfrog public results.
Example 1: A hospital respondent indicates that Safe Practices 21 and 23 do not apply. Total
Available Points for all Safe Practices is 687 = 737 less 30 points for SP21 and 20 points for SP23.
4. Points Earned: Total points earned for each Safe Practice/Element is the sum of the points for each
checkbox marked in that respective Safe Practice/Element (the exception being Safe Practice #9,
whereby hospitals indicating that they have current Magnet status designation, as determined by the
American Nurses Credentialing Center (ANCC), will automatically receive full credit).
5. Overall Points: The overall score of each survey is the sum of all Points Earned for each Safe
Practice/Element, re-balanced for Safe Practices that are NA. The sum of Points Earned across all
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Safe Practices/Elements is multiplied by the ratio of 737 Maximum Points to the sum of Available
Points for each Practice/Element.
Example 2: Continuing from Example 1, Points Earned across the 15 Safe Practices that do apply
total 624.30. Overall Points are 669.74 = 624.30 x ( 737 / 687 ).
6. Final Scoring: All responding hospitals are stratified into performance categories based on Overall
Points.
7. Performance category cutpoints are based on the distribution of surveys submitted as of June 30,
2011. The distribution of scores including new or updated survey results will be reviewed periodically
to determine if there are compelling reasons to revise these performance category cutpoints further,
but there are no current plans or commitments to change the cutpoints again during the 2011 survey
cycle.
Updated Submissions: Hospitals may update and resubmit their surveys as often as needed to reflect
actual progress achieved or additional commitments undertaken in these patient safety areas. Hospitals
submitting new information will have new results replace the posted results from the prior submission to
reflect this progress, consistent with Leapfrog’s monthly update of survey results.
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Section 7: Managing Serious Errors
What’s New in the 2011 Survey
1. Two additional ICUs have been added to the current list of ICUs for which hospitals are asked to
report their rates of central line associated bloodstream infections (CLABSI) acquired during the
ICU stay. The two additional ICUs are the Neurosurgical ICU and the Surgical Cardiothoracic
ICU. For scoring purposes, hospital performance in these two ICUs will be incorporated into a
hospital’s standardized infection ratio (SIR), a summary value developed by the Centers for
Disease Control and Prevention (CDC) and used by Leapfrog and other national reporting entities
to report a hospital’s performance across all ICUs.
2. Hospitals that receive an aggregated central line associated bloodstream infection (CLABSI)
score of “Willing to Report” (1 bar), as calculated from their observed CLABSI rates, will earn one
bar incremental credit on their aggregated score if they indicated that they utilize personnel
trained in human factors engineering in conducting root-cause analyses of adverse events. This
“extra credit” opportunity is offered as an alternative to participation in ON THE CUSP: STOP
BSI.
3. The criteria for laboratory-confirmed bloodstream infections have been updated to reflect the
latest CDC/NSHN definitions.
Change Summary since Release
None. If substantive changes are made to this section of the survey after release on April 1, they will be
documented in this Change Summary section.
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Updated the performance category cutpoints for hospital-acquired pressure ulcers and injuries.
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Never Events
Never Events Frequently Asked Questions (FAQs)
1. What are never events?
The National Quality Forum, a nonprofit national coalition of physicians, hospitals, businesses
and policy-makers, has identified 28 events as occurrences that should never happen in a
hospital and can be prevented. They termed them “serious reportable events”, or never events.
They include surgical events such as performing the wrong surgical procedure, product or device
events such as contaminated drugs or devices and criminal events such as abduction of a
patient. To see a complete list of never events go to:
http://www.qualityforum.org/Publications/2007/03/Serious_Reportable_Events_in_Healthcare–
2006_Update.aspx
2. How often do never events occur?
By definition, never events are incredibly rare. They are also rarely disclosed, except in
confidentiality to reporting programs like The Joint Commission, so precise numbers on their
frequency are not available. Some states, such as Minnesota, now have mandatory reporting
laws that track never events. In the past few years, Minnesota has averaged around 100 reported
never events per year.
3. If never events are so rare, why is Leapfrog choosing to focus on them?
While never events are rare, they do sometimes happen – causing serious harm to the patient.
Leapfrog wants to promote patient safety and quality in a manner consistent with the
recommendations of the National Quality Forum’s report. We also want to recognize those
hospitals that are leading the effort in patient safety by being willing to apologize to the patient
affected by the never event, investigate its cause and improve processes in response to their
analysis, and be willing to share their policy with patients, families, and others.
4. How does the issue of never events relate to other Leapfrog initiatives?
Leapfrog’s “leaps”, which in four categories address the Safe Practices for Better Healthcare, also
created by the National Quality Forum, are intended to work together with NQF’s 28 Serious
Reportable Events in addressing both the processes and outcomes related to adverse events.
The implementation of the Safe Practices is intended to prevent adverse events from happening
in the first place. The list of never events identifies the rare events that sometimes do happen and
makes recommendations for what hospitals can and should do if a never event occurs in their
facility.
5. Are there other voices in the health care arena giving attention to the issue of never
events?
Yes. In May 2006 the Centers for Medicare and Medicaid Services came out with a public
statement on never events,
(http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863) in which it announced its
intention to work with Congress, hospitals, and other health care organizations to reduce
payments for never events and to provide more information to the public about when they occur.
6. When reporting Never Events, what “state reporting program for medical errors” applies in
my state?
Congress has passed legislation requiring all states to develop a reporting program for medical
errors. At this time, many states have already enacted or adopted some requirement that
hospitals report serious medical errors or similar adverse events to a state agency(ies). Others
are still implementing legislation or regulations that define that requirement. States that have
developed programs may also define reportable events differently.
7. What if there is no “state reporting program for medical errors” in my state? Do we still
have to report Never Events to meet Leapfrog principles for this policy? To whom?
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Hospitals in states that do not have a state reporting program or requirement in effect can meet
the reporting requirement of Leapfrog’s principles for implementation of a Never Events policy by
reporting all Never Events voluntarily to either the Joint Commission or a Patient Safety
Organization.
If there is no state-required reporting program in effect, no available Patient Safety Organization
to which your hospital can report, and your hospital is not Joint Commission accredited, the
Leapfrog requirement for reporting to an external agency is amended . Hospitals must report the
Never-Event to their governance board. And, hospitals must still perform a root-cause analysis
internally of each Never Event to meet Leapfrog’s principle for full implementation of its Never
Events policy.
8. The reportable adverse events defined by our state’s reporting program don’t include all
28 Never Events endorsed by the National Quality Forum (NQF) and adopted in the
Leapfrog policy. Will reporting only the state-required reportable events to the state
agency suffice for meeting Leapfrog’s requirement for reporting Never Events to an
external agency? Does our hospital have to report other Never Events, as defined by
NQF/Leapfrog, to that state agency even though not required by our state’s reporting
program?
Hospitals should report all state-required reportable events to the state agency. All other Never
Events, as defined by NQF/Leapfrog, that can not be reported to the state agency, should be
reported to the hospital’s governance board.
9. Won’t Leapfrog’s request to have hospitals apologize to the patient put the hospital at risk
for liability?
Not necessarily. Research indicates that malpractice suits are often the result of a failure on the
hospital’s part to communicate openly with the patient and apologize for its error. Patients feel the
most anger when they perceive that no one is willing to take responsibility for the adverse event
that has occurred. A sincere apology from the responsible hospital staff can help to heal the
breach of trust between doctor/hospital and patient. (When Things Go Wrong: Responding to
Adverse Events. Boston, 2006. Mass Coalition for the Prevention of Medical Errors)
10. Is Leapfrog’s belief that hospitals should not bill for never events just a cost savings
measure for employers or health plans?
No. These events are rare and most likely do not represent a significant savings for employers or
health plans. However, for a patient, it could relieve a significant financial burden. We believe that
any patient who suffers from a "never event" should never have to pay for it.
11. How does Leapfrog define “waive cost”?
At its core, Leapfrog’s approach to never events is about improving patient care. While the policy
asks hospitals to refrain from billing either the patient or a third party payer, such as a health plan
or employer company, for any costs directly related to a serious reportable adverse event,
Leapfrog understands that, due to the wide array of circumstances surrounding never events,
specific details of what constitutes “waiving cost” should be handled on a case-by-case basis by
the parties involved.
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Never Events Scoring Algorithm
A hospital’s results are publicly released and displayed on the Leapfrog Group Web site in one of four
categories:
Fully meets standards (4 filled bars) means the hospital has implemented a policy that adheres to all of
the principles of the Leapfrog Group Policy Statement on Serious Reportable Events/ “Never Events”
(answered “Yes” to # 1).
Willing to report (1 filled bar) means the hospital responded to the Leapfrog survey question pertaining
to adoption of this policy, but does not yet meet the criteria for Fully meets standards (answered “No” to
#1).
Declined to respond means the hospital did not respond to this section of the survey, or the hospital was
asked to complete the survey but has not submitted one.
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HAC Reporting Time Periods
Condition
Surveys submitted prior to
November 1, 2011
Surveys submitted on or after
November 1, 2011
Central Line Associated Bloodstream Infections
12 months ending
December 31, 2010
12 months ending
June 30, 2011
12 months ending
December 31, 2010
12 months ending
June 30, 2011
12 months ending
December 31, 2010
12 months ending
June 30, 2011
Pressure Ulcers
Injuries
HAC-1: Central Line Associated Blood Stream Infections
HAC-1 (CLABSI) Specifications: Survey
p.73
HAC-1: Rate of Central Line Associated Bloodstream Infections
Source: National Quality Forum (NQF) Nursing-Sensitive Care Measure 7
Rates will be stratified by ICU type – medical, surgical, medical/surgical, pediatric medical, pediatric
surgical, pediatric medical/surgical, coronary care, surgical cardiothoracic, neurology, and
neurosurgical (see below for definitions of ICU types)
Reporting Time Period: Answer question #2-16 for the 12 months ending :
 December 31, 2010, for surveys submitted prior to November 1, 2011;
 June 30, 2011 for surveys (re)submitted after October 31, 2011.
Definition of ICU Types
Below is a list and brief description of those ICU types for which hospitals should report their central
line associated bloodstream infection (CLABSI) data to the survey:
Source: http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf
Survey ICU Name / CDC ICU Name
Description
Medical / Medical Critical Care
Critical care area for patients who are being
treated for nonsurgical conditions.
Critical care area for the evaluation and
management of patients with serious illness
before and/or after surgery.
An area where critically ill patients with medical
and/or surgical conditions are managed.
Surgical / Surgical Critical Care
Medical/Surgical / Medical/Surgical Critical Care
Pediatric Medical /Pediatric Medical Critical Care
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Pediatric Surgical / Pediatric Surgical Critical
Care
Pediatric Medical/Surgical / Pediatric
Medical/Surgical Critical Care
Coronary Care / Medical Cardiac Critical Care
Section 7: Managing Serious Errors
Critical care area for the evaluation and
management of patients ≤18 years old with
serious illness before and/or after surgery.
An area where critically ill patients <=18 years
old with medical and/or surgical conditions are
managed.
Critical care area specializing in the care of
patients with serious heart problems that do not
require heart surgery. (Note: definition intended
for adult patients, not pediatric).
Surgical Cardiothoracic / Surgical Cardiothoracic
Critical Care
Critical care area specializing in the care of
patients following cardiac and thoracic surgery.
Neurology / Neurologic Critical Care
Critical care area specializing in treating lifethreatening neurological diseases.
Critical care area specializing in the surgical
management of patients with severe
neurological diseases or those at risk for
neurological injury as a result of surgery.
Neurosurgical / Neurosurgical Critical Care
Hospitals should not report rates for adult or pediatric burn, respiratory, or trauma ICUs; or prenatal
ICUs or neonatal ICUs to the survey.
Not every hospital will have all of the intensive care units listed in the table above.
Hospitals decide which type of ICU they have by measuring the type of patients that are cared for in
that area and applying the 80% Rule. For instance, the medical ICU serves non-surgical patients, so if
a facility finds that 80 percent of their critical care patients are non-surgical, that facility would have a
medical ICU according to NHSN definitions.
If a hospital operates an ICU that is does not consistently have 80% of a specific type of patient (e.g.
an ICU averages 50% medical patients, 50% surgical patients), that ICU should be considered a
medical-surgical ICU.
Hospitals should report on all patients cared for in that particular ICU type, regardless of their actual
status (e.g. include any surgical patients cared for in a medical ICU in the medical ICU reporting).
Directions for using central line associated bloodstream infection (CLABSI) data reported to
the Centers for Disease Control and Prevention/National Healthcare Safety Network
(CDC/NHSN) for completing questions #7-16:
Hospitals are able to use the central line associated bloodstream infection (CLABSI) data they report
to the Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN)
in completing columns (b) and (c) for questions #7-16.
Important Note: The NQF-endorsed CLABSI measure, when used for public reporting purposes, only
includes those central line associated bloodstream infections that meet CDC Criterion 1 or 2 (see
http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf for details on definitions).
Hospitals that are using their CDC/NHSN data to complete column (c) should only include those
infections that meet these two criteria.
Hospitals using CDC/NHSN data should report their denominators in column (b) and numerators in
column (c). Actual rates will be calculated by Leapfrog.
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Hospitals that do not report CLABSI data to CDC/NHSN should use the specifications listed below in
reporting denominators and numerators.
Denominator: Central line-days for patients with a central line while in the specified ICU
Eligible cases = cases with a central line while in the specified ICU during the reporting period,
removing any patient that is part of the Excluded Populations below
Note: While hospitals will not report the eligible cases in the denominator for each ICU type to the
survey, hospitals will need to use this eligible case list for accurately identifying central line days and
central line associated bloodstream infections.
Calculate the central line-days for the eligible cases and report them in column (b). (For details on this
calculation, see Central Line-Days below.)
Note: Central line-days must be calculated and reported separately for each of the ten types of ICUs
your hospital operates. Results for multiple, distinct but separate ICUs of the same type should be
combined and reported in total for that respective ICU type.
Excluded Populations:
Exclude any patient stay in that ICU with:
 a secondary bloodstream infection; or
 a bloodstream infection present or incubating on admission or transfer to the ICU; or
 clinical sespsis; or
 the location of attribution of patient’s infection is a non-ICU location (e.g. trauma, ED, etc.)

Do not double-count a case where the patient was transferred to another ICU of the same type
with the line in place
Numerator: Number of eligible cases included in the denominator that have an infection that meets
the CDC Criterion 1 or 2 for laboratory-confirmed bloodstream infections:


CDC Criterion 1 -- Patient has a recognized pathogen cultured from one or more blood
cultures and organism cultured from blood is not related to an infection at another site,
or
Criterion 2 - Patient has at least one of the following signs or symptoms: fever (>38 º C), chills,
or hypotension, and signs and symptoms and positive laboratory results are not related to an
infection at another site and common skin contaminant (i.e., diphtheroids [Corynebacterium
spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative
staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp.,
Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions.
Source: Central Line-Associated Bloodstream Infection (CLABSI) Event Device-Associated
Module (June 2010)
http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf
Report these cases in column (c).
Central Line-Days:
1. Count each day the patient was in the ICU and had a central line in place all day or for any
portion of a day.
2. A day (or any portion thereof) runs from midnight to midnight (00:00 – 23:59)
3. Count whole days only, not fractional days, even if the central line was only in place for a portion
of that day.
4. For patients admitted to or transferred into the ICU with a central line in place at arrival in the ICU,
count that day in Central Line-Days
5. For patients transferred or discharged from or dying in the ICU with a central line in place at
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discharge, transfer or death, count that day in Central Line-Days. Exception: If a patient was
transferred to another ICU of the same type with the line in place, do NOT count the day
transferred out but count the day transferred in to the other unit, i.e., count this day only once for
this type of ICU.
6. For patients transferred between ICUs of different types with a central line in place at time of
transfer, count the day of transfer once for each ICU type.
7. Do not count the same day more than once in Central Line-Days for any ICU (of the same type),
even if (a) more than one central line was concurrently in place for the patient during that day or
(b) a central line was removed and inserted again during the same day.
HAC-1 (CLABSI) Scoring Algorithm
A hospital’s rate of central line-associated bloodstream (CLABSI) infections is calculated for each type of
ICU in which they care for patients with central lines (e.g. medical, surgical, medical-surgical, pediatric
medical, pediatric surgical, pediatric medical-surgical, coronary care, surgical cardiothoracic, neurology,
and/or neurosurgical).
The rate of central line-associated bloodstream infections in an ICU is calculated by dividing the number
of central line-associated bloodstream infections acquired in the ICU by the number of central line days in
that same ICU.
CLABSI rates are reported as a rate of occurrence per 1,000 central line days by ICU type.
Note: Major teaching hospitals will have their medical and medical-surgical central line-associated
bloodstream infection rates reported independently from other hospitals.
Summary Score
A standardized infection ratio (SIR) will be calculated for each hospital, which will serve as the hospital’s
summary CLABSI score.
The SIR calculation divides the total number of observed CLABSI events at a hospital by an “expected”
number of events.
The “expected” number of events is calculated by multiplying the national CLABSI rate from the standard
population by the observed number of central line days for each type of ICU type in which the hospital
reported. This "expected" value can also be understood as a prediction or projection.
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Below are the standard population CLABSI rates that will be used in calculating a hospital’s SIR. They
are based on the national NHSN data.
ICU Type
Medical – Major Teaching
Medical –Others
Surgical
Medical/Surgical – Major Teaching
Medical/Surgical – Others
Pediatric (Pooled for all types)
Medical Cardiac (Coronary Care)
Surgical cardiothoracic
Neurologic
Neurosurgical
Mean NHSN CLABSI
Rates for 2006-20083
(Standard Population)
2.5679
1.8958
2.3055
2.1078
1.4801
2.9391
2.0073
1.3891
1.3510
2.4615
A hospital’s standardized infection ratio is used to determine in which performance category a hospital is
placed:
•
•
•
•
•
•
Fully meets standards (4 filled bars) means the hospital has a standardized infection ratio of
0.00.
Substantial progress (3 filled bars) means the hospital has a standardized infection ratio
greater than 0.00 and less than or equal to 0.90.
Some progress (2 filled bars) means:
 the hospital has a standardized infection ratio greater than 0.90 and less than or
equal to 1.10; or
 the hospital has a standardized infection ratio greater than 1.10 and participates in
their state’s ON THE CUSP: STOP BSI prevention program (or for Pediatric
hospitals, NACHRI’s Catheter-associated Blood Stream Infections Collaborative); or
 the hospital has a standardized infection ratio greater than 1.10 and utilizes
personnel trained in human factors engineering in conducting root-cause analyses or
adverse events
Willing to report (1 filled bar) means:
 the hospital has a standardized infection ratio greater than 1.10 and does not
participate in their state’s ON THE CUSP: STOP BSI prevention program (or for
Pediatric hospitals, NACHRI’s Catheter-associated Blood Stream Infections
Collaborative); or
 the hospital has a standardized infection ratio greater than 1.10 and does not utilize
personnel trained in human factors engineering in conducting root-cause analyses or
adverse events.
Declined to respond means the hospital did not respond to this section of the survey, or the
hospital was asked to complete the survey, but has not submitted one.
Does Not Apply means that the hospital does not care for patients with central lines in ICUs
or the hospital reported too small of a sample size to report their results reliably (i.e. the
hospital reported <1,000 central line-days total across all ICUs AND < 3 central line
associated bloodstream infections total across all ICUs).
3
Rates taken from the National Healthcare Safety Network (NHSN) report: Data summary for 2006
through 2008, issued December 2009 (Table 3).
http://www.cdc.gov/nhsn/PDFs/dataStat/2009NHSNReport.PDF
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Below is an example of the standardized infection ratio calculation:
Hospital Reported CLABSI Data
# CLABSI
# Central line-days
CLABSI Rate
(per1,000 central
line- days
Mean NHSN
CLABSI Rates for
2006-2008
(Standard
Population)
CLABSI Rate
(per1,000 central
line- days
Neurologic
2
1,200
1.67
1.3510
Surgical
5
4,000
1.25
2.3055
ICU Type
SIR = Observed # events / Expected # events
Observed # events
= Neurologic # CLABSI + Surgical # CLABSI
=2+5
=7
Expected # events
= (Neurologic Observed Central line-days * Neurologic Std Pop CLABSI rate) +
(Surgical Observed Central line-days * Surgical Std Pop CLABSI rate)
= (1,200 * 1.3510/1,000) + (4,000 * 2.3055/1,000)
= 1.621+ 9.222 = 10.843
SIR
= Observed/Expected
= 7 / 10.843
= 0.6456
A standardized infection ratio (SIR) of 0.6456 would place this hospital in the “Substantial Progress”
performance category.
Public Reporting
In addition to reporting the hospital’s performance category, the hospital’s standardized infection ratio
(SIR), the number of central line associated bloodstream infections, and central line days for each ICU
type reported will be reported on a secondary webpage accessed via drill-down from the main results
page.
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HAC-2: Hospital-Acquired Pressure Ulcer
HAC-2 (Pressure Ulcer) Specifications: Survey
p.75
HAC-2: Rate of Pressure Ulcers
Source: The Leapfrog Group
Reporting Time Period: 12 months ending :
 December 31, 2010, for surveys submitted prior to November 1, 2011;
 June 30, 2011 for surveys (re)submitted after October 31, 2011.
Denominator: Total inpatient days for the population of interest.
Step 1: Begin with all adult inpatient discharges (including deaths) during the 12-month reporting
period (Q18)
Step 2: Using the Excluded Populations below, identify any discharge in Q18 with this condition
present on admission and report that number in Q19.
Step 3: Subtract/exclude discharges identified in Q19 from the discharges identified in Q18. Report
the count of the remaining eligible cases in Q20.
Step 4: Calculate the total inpatient days for the cases reported in Q20 and report this value in Q21.
See Total Inpatient Days at the end of this document for details on how to calculate this value.
Excluded Populations:
Eligible cases should exclude any hospital discharge where:
 Patient age is less than 18 years, or
 Any ICD-9 diagnosis code of 707.23 or 707.24 is present on the case AND that diagnosis
code is also coded with a POA indicator of:
 Y (yes, present on admission), or
 W (unable to clinically determine if condition POA), or
indicating that the condition was or may have been present at admission.
Only these two POA codes are considered to indicate that the condition was present on
admission.
Report in Q19 the number of cases excluded.
Numerator: Number of cases in the denominator (Q20) with any ICD-9 diagnosis code in a
secondary diagnosis field of 707.23 or 707.24.
(Since eligible cases in the denominator already exclude patients with this condition present at
admission, the numerator cases are considered to have acquired the condition during the hospital
stay.)
Report these cases in Q22.
Total Inpatient Days: Only applicable to HAC-2 and HAC-3 measures.
(For Central-Line Days, see the definition in HAC-1 above.)
Total inpatient days should be calculated as follows:
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



Section 7: Managing Serious Errors
For each patient, count from admission to discharge, including day of admission but excluding
day of discharge, except if discharged (including died) on the same day as admission date, count
one(1) patient day. Date of death is considered date discharged.
The number of inpatient days for each patient is a whole number of days, with a minimum one(1)
day stayed. Do not count fractional or partial days for late discharge or temporary transfer to
another facility, e.g., for testing or procedure.
Since the numerator is based on data for discharges during the 12-month reporting period, count
patient days only for cases discharged during that same 12-month period. For these discharges,
count patient days for the entire stay, including any portion of a stay occurring prior to the start of
that 12-month period. Do not count any portion of any stay with a discharge date after that 12month period, even if a portion of that stay occurred during the 12-month period. Example: Most
recent 12-month period available= 12 months ending 12/31/2010. Case #1 admitted 12/28/2009
discharged 1/02/2010 counts as a case with 5 inpatient days, including 4 inpatient days in 2009.
Case #2 admitted 12/29/2010 discharged 1/03/2011 does not count in the inpatient days; no days
should be accumulated for this case for the 12-month period since the discharge date falls after
the 12-month period.
Count Total Inpatient Days separately for HAC-2 and HAC-3 since the exclusion criteria for
present-on-admission (POA) differ for the two measures. For this reason, Total Inpatient Days for
HAC-2 denominator (question 21) and HAC-3 denominator (question 26) may differ somewhat
from each other.
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HAC-3: Hospital-Acquired Injuries
HAC-3 (Injuries) Specifications: Survey
p.76
HAC-3: Rate of Hospital-Acquired Injuries
Source: The Leapfrog Group
Reporting Time Period: 12 months ending :
 December 31, 2010, for surveys submitted prior to November 1, 2011;
 June 30, 2011 for surveys (re)submitted after October 31, 2011.
Denominator: Total inpatient days for eligible cases
Step 1: Begin with all adult inpatient discharges (including deaths) during the 12-month reporting
period (Q23)
Step 2: Using the Excluded Populations below, identify any discharge in Q23 with this condition
present on admission and report that number in Q24.
Step 3: Subtract/exclude discharges identified in Q24 from the discharges identified in Q23. Report
the count of the remaining eligible cases in Q25.
Step 4: Calculate the total inpatient days for the cases reported in Q25 and report this value in Q26.
See Total Inpatient Days at the end of this document for details on how to calculate this value.
Excluded Populations:
Eligible cases should exclude any hospital discharge where:
 Patient age is less than 18 years, or
 Any ICD-9 diagnosis code in the ranges: 800-829, 830-839, 850-854, 925-929, 940-949, 991994 is present on the case AND that diagnosis code is also coded with a POA indicator of:
 Y (yes, present on admission), or
 W (unable to clinically determine if condition POA)
indicating that the condition was or may have been present at admission. Only these two
POA codes are considered to indicate that the condition was present on admission.
 The patient has an intraoperative fracture as a complication of orthopedic surgery.
Report in Q24 the number of cases excluded.
Numerator: Number of cases included in the denominator (Q25) with any ICD-9 code in a secondary
diagnosis field in the ranges: 800-829, 830-839, 850-854, 925-929, 940-949, 991-994.
(Since eligible cases in the denominator already exclude patients with this condition present at
admission, the numerator cases are considered to have acquired the injury during the hospital stay.)
Report these cases in Q27.
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HAC-2 (Pressure Ulcer) and HAC-3 (Injuries) Frequently Asked
Questions (FAQs)
1. Should psych and rehab patients be included in the numerator and denominator for the
hospital-acquired conditions?
Hospitals should include in the numerator and denominator any patient for which they code
present-on-admission (POA). This would include most short-stay psych and rehab patients.
HAC-2 (Pressure Ulcer) and HAC-3 (Injuries) Scoring Algorithm
A hospital’s rate of hospital-acquired pressure ulcers and rate of hospital-acquired injuries is calculated
and compared to the rates of other hospitals.
The rate of the hospital-acquired condition is calculated by dividing the number of discharges with the
condition, which was not present on admission (question #22 or #27) by the number of inpatient days
(question #21 or #26).
Rates of the hospital-acquired pressure ulcers and hospital-acquired injuries will be reported as a rate of
occurrence per 1,000 inpatient days. All responding hospitals are stratified into performance categories
based on their reported rates.
A hospital’s results for each condition are publicly released and displayed on the Leapfrog Group Web
site in one of five categories:
 Fully meets standards (full credit -- 4 filled bars) means the hospital is in the lowest (best)
performance category.
 Substantial progress (¾-credit -- 3 filled bars) means the hospital is below the midpoint
(median), but not in the lowest performance category.
 Some progress (½-credit -- 2 filled bars) means the hospital is above midpoint (median), but not
in the highest performance category.
 Willing to report (¼-credit -- 1 filled bar) means the hospital is in the highest (worst) performance
category.
 Declined to respond means the hospital did not respond to this section of the survey, or the
hospital was asked to complete the survey but has not submitted one..
 Response Not Required: Reporting on these two conditions is strictly voluntary for critical
access hospitals.
 Does Not Apply: Standard does not apply to children’s hospitals. .
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For hospital-acquired pressure ulcers, performance category cutpoints are based on the distribution of
surveys submitted as of June 30, 2011, the first deadline for hospitals to submit 2011 surveys. For
hospital-acquired injuries, performance category cutpoints are based on the distribution of surveys
submitted as of June 30, 2011. These quartile cutpoints will remain in place for the entire survey reporting
cycle, unless it is determined that there are compelling reasons to make revisions. However, at this time,
there are no current plans or commitments to change the cutpoints.
Measure
Hospital-Acquired Pressure Ulcers
Hospital-Acquired Injuries
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HAC Cutpoints
Fully meets
Substantial
Some
Willing to
standard
progress
progress
report
(4 bars)
(3 bars)
(2 bars)
(1 bar)
Incidence rate per 1000 patient days
Top
Second
Third
Bottom
Performance
Performance
Performance
Performance
Category
Category
Category
Category
0.00
> 0.00 and
<= 0.03
> 0.03 and
<= 0.08
> 0.08
<= 0.10
> 0.10 and
<=0.17
> 0.17 and
<= 0.35
> 0.35
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Section 8: Smooth Patient Scheduling
Section 8: Smooth Patient Scheduling
What’s New in the 2011 Survey
1. This new section of the survey asks hospitals to report on their application of operations
management methods 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.
These are the same methods that manufacturing and other service organizations have already
employed to understand, manage, and optimize the performance of a complex production system
to meet cost, safety, and quality objectives (e.g. Toyota production model). To fully meet
Leapfrog’s standard, hospitals will need to have applied operations management methods to all
of its operating rooms that service inpatients and either document an average utilization of 85%
or greater across those units post-implementation or 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)
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.
Change Summary since Release
None. If substantive changes are made to this section of the survey after release on April 1, they will be
documented in this Change Summary section.
June 8, 2011
Updated the Frequently Asked Questions (FAQs) section to address a number of commonly asked
questions.
May 10, 2011
The scoring algorithm has been updated to reflect that hospitals that are not targeted for reporting on this
section will be reflected as “Response Not Required”.
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Smooth Patient Scheduling Specifications
Specifications: Calculating Available and Utilized ‘Prime Time’ Hours of Operating Rooms that Service
Inpatients
All hospitals should use these specifications and definitions for calculating available and utilized ‘prime
time’ hours of its operating rooms that service inpatients (e.g. exclude those operating rooms that
exclusively service outpatients and those operating rooms that are not located in the main hospital
location).
‘Prime Time’
Each hospital will have its own definition of what constitutes ‘prime time’ for its operating rooms. For a
typical hospital, ‘prime time’ will start around 7 am and go until 3-5 pm.
Available ‘Prime Time’ Hours
These are the hours that the operating rooms were opened and staffed. Across the four week period,
calculate the total ‘prime time’ hours these units were available.
For a typical hospital, the calculation for available ‘prime time’ hours would be:
Available ‘prime time’ hours = number of operating rooms that service inpatients x ‘prime time’ hours x 5
days/week x 4 weeks
Example: A hospital has applied operations management methods to smooth patient flow in their 10
surgical suites. ‘Prime time’ for this hospital is 7 am – 4 pm daily (Monday- Friday).
Available prime time hours = 10 units x 9 hours/day x 5 days/week x 4 weeks = 1800 hours
Note: If a unit is scheduled to close early in the day (i.e. before the end of ‘prime time’), those closed
hours can be deducted from the total.
Utilized ‘Prime Time’ Hours
These are the hours that the inpatient operating rooms were utilized. Across the four week period,
calculate the total ‘prime time’ hours these units were utilized.
Utilized ‘prime time’ hours = cumulative duration of case lengths in ‘prime time’ + cumulative duration of
turnover time in ‘prime time’, across the four week period.
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’.
Smooth Patient Scheduling Frequently Asked Questions
(FAQs)
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1. Which specific "operations management" methods does Leapfrog expect hospitals to
implement?
Leapfrog is not prescribing specific “operations management” methods for hospitals to implement.
Leapfrog suggests that hospitals review both the extensive bibliography and technical
implementation guidelines provided for a list of the types of methods that successful hospitals
have used for smoothing patient flow.
2. If these methods are not already used within our organization, it seems as if will take us a
great deal of resources to implement. What are Leapfrog’s thoughts on using an outside
organization for implementation?
There are a variety of sources hospitals can use to help them in their implementation of these
methods. A web search and/or consulting with other hospitals would be a good place to start for
recommendations.
3. A lot of the measures Leapfrog uses on its survey are endorsed by the National Quality
Forum (NQF). This measure set is currently not endorsed. Is using non-endorsed
measures in its survey a change in philosophy for Leapfrog?
While The Leapfrog Group does use NQF-endorsed measures when and where possible in its
hospital survey, if an endorsed measure does not exist for an important patient safety or
efficiency metric, for which there is peer-reviewed evidence, then Leapfrog has, and will continue
to use, its discretion in including non-endorsed measures on the survey.
4. With this measure set, is Leapfrog asking hospitals to become a 7-day hospital?
Leapfrog does not require hospitals to move to a 7-day concept, as we recognize the significant
cultural shift that would require. That said, Leapfrog does see a 7-day hospital concept as a good
opportunity for hospitals to use existing resources more efficiently.
5. We note that the ‘Admission Variability Calculator’ is designed only for 5-day hospitals.
Our hospital is striving to be a 7-day hospital. Can the calculator be adapted to our 7-day
approach?
If hospitals are interested in looking at variability across seven days a week, they are able to add
in two rows per week into the calculator. The most likely result of looking at seven days is an
increase in variability, demonstrating a greater need to implement smoothing methods.
6. What is the objective of the ‘Admission Variability Calculator’?
The admission variability calculator is designed to help hospitals understand the magnitude of the
variability in their scheduled and unscheduled admissions. Optimally, the flow smoothing process
involves separating your hospital’s scheduled and unscheduled procedures into separate flows
(and separate resources).
7. Over 40% of my hospital’s surgical cases are non-scheduled. While some hospitals know
weeks in advance what their surgery schedule looks like, our surgical schedule is
completed one business day in advance. Our hospital must be flexible enough to adjust
for the acuity of our patient population and a very high proportion of unscheduled
admissions. Does this measure set apply to my hospital?
With a high percentage of your hospital’s admissions being unscheduled, separating your
scheduled and unscheduled patient flows would benefit your hospital even more than hospitals
that have a greater percentage of scheduled admissions.
8. Why is Leapfrog asking hospitals to just smooth admissions in operating rooms that
service inpatients?
Leapfrog is asking hospital to ‘start small’ with smoothing patient flow, by asking them to just
focus on inpatient operating rooms. If your hospital believes it can apply these methods to
additional areas of the hospital, than please feel free to do so.
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9. What specific quantitative benchmarks should hospitals be able to achieve with
implementation of these methods?
The standards for which hospitals will be measured against is an average utilization of 85% or
greater across those units post-implementation, a 5% improvement in utilization of existing
capacities at the end of year 1, a 10% improvement in utilization of existing capacities at the end
of year 2, and a 15% improvement in utilization of existing capacities overall.
10. Would urgent cases that bypass the ED and go directly to an operating room be
considered to be part of the unscheduled category?
Yes, urgent cases that bypass the ED and go directly into surgery would be considered
unscheduled cases.
11. Should we exclude mothers of newborns from the smoothing admissions?
There is no reason to exclude mothers of expectant moms from the flow smoothing exercise.
They should be treated like any other ‘scheduled’ or ‘unscheduled’ admission. Some of the early
work on admission smoothing was done in OB units.
12. Do a hospital’s elective inpatient surgeries need to make up 10% or more of their total
inpatient admissions to be successful on this part of the survey?
Hospitals do not need for their elective inpatient surgeries during the reporting period to be at
10% or greater to be successful on this part of the survey. The question in the survey about
elective inpatient surgeries making up 10% or more of total inpatient admissions is simply a filter
question.
13. Should hospitals only consider surgical patients in calculating their ratio of absolute
deviations in the Admission Variability Calculator?
No. Hospitals should consider both surgical and non-surgical cases when identifying the number
of scheduled and unscheduled admissions.
14. Our hospital has dedicated operating rooms for certain service lines (e.g., cardiac), for
which our management wants to keep dedicated for patient access reasons. Should these
ORs be included in the calculations for utilized and available ‘prime time’ hours?
Yes, these units need to be included. While separating elective and emergent flows may not be
applicable in these ORs (given the small number of dedicated ORs), smoothing elective cases
within these dedicated units across the week is still very much applicable. Minimizing the
peak/valley cycle in these ORs is equally important as the other ORs.
Smooth Patient Scheduling Scoring Algorithm
Fully meets the standard (4 bars):
The hospital has applied operations management methods (e.g. queuing theory, variability
management) to smooth patient flow across all its operating rooms that service inpatients and can
document an average utilization of 85% or greater across those units post-implementation –OR- 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- a 15% improvement in
utilization across all units.
Substantial Progress (3 bars):
The hospital has applied operations management methods (e.g. queuing theory, variability
management) to smooth patient flow across all of its operating rooms that service inpatients, but can
not document an average utilization of 85% or greater across those units post-implementation –ORat 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- a 15%
improvement in utilization across all units.
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Some Progress (2 bars):
The hospital has completed at least two of the following three preparation steps:
 The hospital has a written plan for applying operations management methods (e.g. queuing
theory, variability management) to smooth patient flow across its operating rooms that service
inpatients within the next 12 months (Answered “Yes” to question #11).
 The hospital board has approved a dedicated budget for the application of operations
management methods (e.g. queuing theory, variability management) to smooth patient flow in its
operating rooms that service inpatients (Answered “Yes” to question #12).
 The chief of one surgical department of the hospital contacted and held discussions with a peer at
another hospital that has already applied operations management methods (e.g. queuing theory,
variability management) to smooth patient flow to increase unit utilization by at least 15%.
(Answered “Yes” to question #13).
Willing to Report (1 bar):
The hospital provided responses to this section of the survey, including their ratio from the Admission
Variability Calculator (question #4), but did not meet the criteria for “Some Progress”.
Standard Does Not Apply:
Hospitals with fewer than 25 staffed beds (Answered “No” to question #1) –or- hospitals that do not
operate more than one operating room that services inpatients (Answered “No” to question #2).
Response Not Required:
The hospital was not targeted for reporting to the survey by a Leapfrog regional roll-out (RRO) and
did not provide responses to this section – or – the hospital reported that elective surgeries made up
less than 10% of their total admissions (Answered “No” to question #3) and choose not to provide
responses for the remaining questions – or the hospital was not targeted for reporting on this section
of the survey.
Declined to Respond:
The hospital was targeted for reporting to the survey by a Leapfrog regional roll-out (RRO) and did
not provide responses to this section.
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Section 9: Patient Experience of Care
Section 9: Patient Experience of Care
What’s New in the 2011 Survey
1. In this new section of the survey, which focuses on patients’ experience of care in hospitals,
hospitals are asked to report three composite scores from their latest HCAHPS results (as
displayed on HospitalCompare). The three composite scores include: Pain Management,
Communication about Medicines, and Discharge Information. Hospital performance on each
composite will be compared to national thresholds and summarized into a single score. Reporting
of this HCAHPS bundle will be voluntary for critical access hospitals and other PPS-exempt
hospitals and will be non-applicable to children’s hospitals.
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
Change Summary since Release
June 8, 2011
Updated the link to CMS’s HospitalCompare website to the correct URL.
April 5, 2011
The instructions in Section 9 (Patient Experience of Care) were updated to clarify that this section is
voluntary for all PPS-exempt hospitals. Hospitals that do not want to voluntarily report their HCAHPS
results will need to answer No to question #1 and their score will be shown as ‘Response Not Required’.
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HCAHPS Bundle Specifications
Reporting period: Hospitals should provide their scores for the most recent period of data available as
reported by CMS on HospitalCompare (http://hospitalcompare.hhs.gov).
Report the score for the following three composite measures:
 Pain Management --Patients who reported their pain was “Always” well controlled.
 Communication About Medications-- Patients who reported that staff “Always” explained about
medicines before giving to them.
 Discharge Home -- Patients at each hospital who reported that YES, they were given information
about what to do during their recovery at home
HCAHPS Bundle Frequently Asked Questions (FAQs)
1. Does Leapfrog want hospitals to report their case- and mode-adjusted HCAHPS scores or
their raw scores?
Leapfrog wants hospitals to report their HCAHPS scores as posted on the HospitalCompare
website (https://www.hhs.hospitalcompare.gov). The scores posted on HospitalCompare are
adjusted for both case severity and survey mode and reflect a hospital’s 12-month average
performance.
2. What reporting period does Leapfrog want hospitals to use for reporting their HCAHPS
scores?
Hospitals should report the most recent data available on HospitalCompare when reporting to the
Leapfrog survey.
3. My hospital is part of a hospital system and shares a Medicare Provider Number (MPN)
with other hospitals. How should we report our HCAHPS scores to the Leapfrog Hospital
Survey?
Hospitals should report their HCAHPS data as displayed on HospitalCompare. This could result
in two or more hospitals submitting identical data. When reporting to Leapfrog, hospitals should
not separate the data by hospital, as the raw data will not be mode or case-mix adjusted.
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HCAHPS Bundle Scoring Algorithm
Hospitals earn points based on their composite scores and how those scores compare to the national
quartile thresholds listed below:
 Hospital did not provide data for the measure – 0 pts
 Hospital’s score is in the bottom quartile – 1 pt
 Hospital’s score is in the 3rd quartile – 2 pts
 Hospital’s score is in the 2nd quartile – 3 pts
 Hospital’s score is in the Top quartile – 4 pts
For each measure, a maximum of 4 pts is possible.
HCAHPS Composite
Measure
Bottom
Quartile
Scores
Quartile
3rd
2nd
Quartile
Quartile
Scores
Score
Top
Quartile
Scores
Pain Management:
“Patients who
reported that their
pain was "Always"
well controlled.”
Communication
About Medications:
“Patients who
reported that staff
"Always" explained
about medicines
before giving it to
them.”
Discharge Home:
“Patients at each
hospital who
reported that YES,
they were given
information about
what to do during
their recovery at
home.”
0-65
66-68
69-71
72-100
0-55
56-58
59-62
63-100
0-77
78-81
82-84
85-100
Quartile thresholds are based on 2009 national HCAHPS data; sample: 3,446 hospitals that reported 100+ completed surveys.
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A summary score is calculated for each hospital by dividing the number of points earned by the number of
points possible (Summary score = Pts earned/ Pts possible).
A hospital’s performance category is determined based on a hospital’s summary score.
Performance
Category
Summary Score
Willing to
Report
(1 bar)
0.01-49.99%
Some
Progress
( 2 bars)
50.00-66.66%
Substantial
Progress
(3 bars)
66.67%-83.32%
Fully Meets
Standards
(4 bars)
83.33-100.00%
Response Not Required:
The hospital reported less than 100 completed surveys and choose not to report the survey results –orthe hospital is a PPS exempt hospital (e.g., critical access hospital, hospital is a member of the Alliance of
Dedicated Cancer Centers) and choose not to report the survey results.
Does Not Apply:
The hospital is a children’s hospital, as they do not participate in IPPS.
Declined to Respond:
The hospital was targeted for reporting to the survey by a Leapfrog regional roll-out (RRO) and did not
provide responses to this section –or- the hospital did not provide their survey results on all three
measures (summary score = 0%).
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Leapfrog Hospital Survey
Reference Documentation Complete
On behalf of The Leapfrog Group and its members, we appreciate
your hospital’s continued commitment to transparency and participation in
the Leapfrog Hospital Survey.
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