New Measures for 2008 Leapfrog Survey
Efficiency Measures for CABG and PCI
Hospitals will be asked to report on the efficiency of care provided to CABG and PCI patients.
The
proposed measures and example risk factors are outlined below.
The case criteria for the CABG efficiency counts will be the same criteria as the volume counting
criteria. The case criteria for PCI efficiency counts will have some additional exclusion criteria as to
eliminate outpatient PCIs from ALOS, readmissions, and risk-factor case counts.
Hospitals must have at least 30 cases for a condition (CABG or PCI) that are treated and not
transferred out in order to report on efficiency of care. Hospitals that do not meet the 30 cases for
a condition will be able to indicate that in the survey.
The efficiency measures and the pro forma risk factors, both which are subject to revision are as
follows:
Coronary Artery Bypass Graft (CABG) – Efficiency Measures
See general specifications for computing and reporting efficiency measures, as well as inclusion/exclusion
criteria particular to this procedure.
1) Total number of discharges with a CABG procedure at this hospital location
for the volume reporting period meeting the inclusion/exclusion criteria for
measuring efficiency (i.e. overall hospital volume count for the procedure).
_______
All remaining questions pertain to these cases only
2) Number of discharges reported in question 1 which were followed by a readmission
to this same hospital location, regardless of condition/cause of re-admission, within
15 days following discharge.
3) Average length of stay for discharges reported in question 1.
Report average days/discharge with two decimal place precision
_______
_______
(e.g., 7.65)
4) Number of discharges reported in question 1 which had the selected risk factor present, respectively: (enter 0 if
no discharges had that risk factor present)
Number of Discharges
Description, brief – see detailed specifications
Risk Factor
in Q26 with
Risk Factor Present
RF01
Age >=55
_______
RF02
Male
_______
RF05
Diabetes
_______
RF07
Chronic cerebrovascular disease
_______
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RF08
Chronic renal disease
_______
RF11
COPD
_______
RF12
Cardiomyopathy
_______
RF13
Chronic cardiac conditions
_______
RF15
Atherosclerosis and lipid disorders
_______
RF16
PCI
_______
RF18
Musculoskeletal conditions
_______
RF19
AMI
_______
RF20
CAD without prior CABG
_______
RF21
CAD with prior CABG
_______
Percutaneous Coronary Intervention (PCI) – Efficiency Measures
See general specifications for computing and reporting efficiency measures, as well as inclusion/exclusion
criteria particular to this procedure.
1) Total number of discharges with a PCI procedure at this hospital location
for the volume reporting period meeting the inclusion/exclusion criteria for
measuring efficiency (i.e. overall hospital volume count for the procedure).
_______
All remaining questions pertain to these cases only
2) Number of discharges reported in question 1 which were followed by a readmission
to this same hospital location, regardless of condition/cause of re-admission, within
15 days following discharge.
3) Average length of stay for discharges reported in question 1.
Report average days/discharge with two decimal place precision
_______
_______
(e.g., 7.65)
4) Number of discharges reported in question 1 which had the selected risk factor present, respectively: (enter 0 if
no discharges had that risk factor present)
Number of Discharges
Description, brief – see detailed specifications
Risk Factor
in Q21 with
Risk Factor Present
RF01
Age >=55
_______
RF02
Male
_______
RF03
Site of infarction: anterior or anteriolateral
_______
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RF04
Site of infarction: subendocardial
_______
RF05
Diabetes
_______
RF06
Cancer
_______
RF07
Chronic cerebrovascular disease
_______
RF08
Chronic renal disease
_______
RF09
Chronic liver disease
_______
RF10
Obesity
_______
COPD (definition differs from RF36)
RF11
_______
RF12
Cardiomyopathy
_______
RF13
Chronic cardiac conditions
_______
RF14
History of PTCA
_______
RF15
Atherosclerosis and lipid disorders
_______
RF17
CABG
_______
RF18
Musculoskeletal conditions
_______
RF19
AMI
_______
2008 Leapfrog Hospital Quality and Patient Safety Survey
2008 New Measures
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Pneumonia and AMI Quality of Care Process Measures
Joint Commission measures, endorsed by the National Quality Forum, which measure quality-ofcare and safety processes, will be used to assess the adoption of safety practices for pneumonia and
AMI patients.
Hospitals that report to The Joint Commission (TJC) will be able to use their TJC submitted data to
complete this section of the survey.
For hospitals that do not report to TJC, measure specifications
that mirror the TJC measures will be provided.
Hospitals must have at least 30 cases for a condition (Pneumonia or AMI) that are treated and not
transferred out in order to report on quality of care. Hospitals that do not meet the 30 cases for a
condition will be able to indicate that in the survey.
The measures are as follows:
Acute Myocardial Infarctions (AMI) – Process Measures of Quality
Indicate your hospital’s adherence to nationally endorsed procedure-specific process measures of quality specific
to this procedure, if measured. (see Process Measures link on survey home page)
Instructions
For each of the seven guidelines, indicate:
(a) whether your hospital has performed a medical record audit on all cases (or a sufficient sample of them)
for AMI patients for the 12-month period ending { December 31, 2007 | June 30, 2007 } and measured
adherence to the Leapfrog expert panel-endorsed clinical process guideline for this procedure.*
If no, skip (b) and (c) for this procedure.
(b) the number of cases measured against the guideline, either all cases or the sample size, for this procedure
i.e., number of cases audited and meeting the criteria for inclusion in the denominator of the measure.
(c) The number of cases in (b) that adhere to the Leapfrog expert panel-endorsed clinical process guideline
for this procedure (numerator).
* Responses can and should be based on the same data reported to Joint Commission for National Hospital Quality
Measures where those data have been reported and accepted by the Joint Commission. Otherwise, hospitals can
measure and report results as described here and in the Process Measures specifications (see link on home page).
Guideline
1)
Aspirin at arrival (AMI-1)
2)
Aspirin at discharge (AMI-2)
3)
ACEI for LVSD (AMI-3)
4)
Smoking cessation counseling
(AMI-4)
Beta blocker at discharge (AMI-5)
5)
(a)
Measured?
if No,
skip (b) and (c)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
(b)
# Cases
Measured
(denominator)
( c)
# Cases Adhere
(numerator)
______
______
______
______
______
______
______
______
______
______
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6)
Beta blocker at arrival (AMI-6)
Yes
No
______
______
Pneumonia – Process Measures of Quality
Indicate your hospital’s adherence to nationally endorsed procedure-specific process measures of quality specific
to this procedure, if measured. (see Process Measures link on survey home page)
Instructions
For each of the seven guidelines, indicate:
(d) whether your hospital has performed a medical record audit on all cases (or a sufficient sample of them)
for pneumonia patients for the 12-month period ending { December 31, 2007 | June 30, 2007 } and
measured adherence to the Leapfrog expert panel-endorsed clinical process guideline for this procedure.*
If no, skip (b) and (c) for this procedure.
(e) the number of cases measured against the guideline, either all cases or the sample size, for this procedure
i.e., number of cases audited and meeting the criteria for inclusion in the denominator of the measure.
(f) The number of cases in (b) that adhere to the Leapfrog expert panel-endorsed clinical process guideline
for this procedure (numerator).
* Responses can and should be based on the same data reported to Joint Commission for National Hospital Quality
Measures where those data have been reported and accepted by the Joint Commission. Otherwise, hospitals can
measure and report results as described here and in the Process Measures specifications (see link on home page).
Guideline
1)
Oxygenation assessment (PN-1)
2)
Pneumococcal immunization (PN-2)
3)
Blood cultures prior to antibiotic
(PN-3b)
Smoking cessation counseling
(PN-4)
Antibiotics within 4 hours of ER arrival
(PN-5b)
Influenza immunization (PN-7)
4)
5)
6)
(a)
Measured?
if No,
skip (b) and (c)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
(b)
# Cases
Measured
(denominator)
( c)
# Cases Adhere
(numerator)
______
______
______
______
______
______
______
______
______
______
______
______
2008 Leapfrog Hospital Quality and Patient Safety Survey
2008 New Measures
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Efficiency Measures for Pneumonia and AMI
Hospitals will be asked to report on the efficiency of care provided to pneumonia and AMI patients.
The proposed measures and example risk factors are outlined below.
The case criteria for the efficiency measures will match the case criteria used for the pneumonia and
AMI quality-of-care process measures.
Hospitals must have at least 30 cases for a condition (Pneumonia or AMI) that are treated and not
transferred out in order to report on efficiency of care. Hospitals that do not meet the 30 cases for
a condition will be able to indicate that in the survey.
The efficiency measures and the pro forma risk factors, both which are subject to revision are as
follows:
Acute Myocardial Infarctions (AMI) – Efficiency Measures
See general specifications for computing and reporting efficiency measures, as well as inclusion/exclusion
criteria particular to this procedure.
1) Total number of discharges with principal diagnosis of AMI at this hospital location
for the volume reporting period meeting the inclusion/exclusion criteria for measuring
efficiency (i.e. overall hospital volume count for the condition).
_______
All remaining questions pertain to these cases only
2) Number of discharges reported in question 1 which were followed by a readmission
to this same hospital location, regardless of condition/cause of re-admission, within
15 days following discharge.
3) Average length of stay for discharges reported in question 1.
Report average days/discharge with two decimal place precision
_______
_______
(e.g., 7.65)
4) Number of discharges reported in question 1 which had the selected risk factor present, respectively: (enter 0 if
no discharges had that risk factor present)
Number of Discharges
Description, brief – see detailed specifications
Risk Factor
in Q1 with
Risk Factor Present
RF01
Age >=55
_______
RF02
Male
_______
RF03
Site of infarction: anterior or anteriolateral
_______
RF04
Site of infarction: subendocardial
_______
RF05
Diabetes
_______
RF06
Cancer
_______
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RF07
Chronic cerebrovascular disease
_______
RF08
Chronic renal disease
_______
RF09
Chronic liver disease
_______
RF10
Obesity
_______
RF11
COPD (definition differs from RF36)
_______
RF12
Cardiomyopathy
_______
RF13
Chronic cardiac conditions
_______
RF15
Atherosclerosis and lipid disorders
_______
RF16
PCI
_______
RF17
CABG
_______
RF21
CAD with prior CABG
_______
RF22
Diabetes (RF05) AND Obesity (RF10)
_______
Pneumonia – Efficiency Measures
See general specifications for computing and reporting efficiency measures, as well as inclusion/exclusion
criteria particular to this procedure.
1) Total number of discharges with principal diagnosis of pneumonia at this hospital
location for the volume reporting period meeting the inclusion/exclusion criteria for
measuring efficiency (i.e. overall hospital volume count for the condition).
_______
All remaining questions pertain to these cases only
2) Number of discharges reported in question 1 which were followed by a readmission
to this same hospital location, regardless of condition/cause of re-admission, within
15 days following discharge.
3) Average length of stay for discharges reported in question 1.
Report average days/discharge with two decimal place precision
_______
_______
(e.g., 7.65)
4) Number of discharges reported in question 1 which had the selected risk factor present, respectively: (enter 0 if
no discharges had that risk factor present)
Number of Discharges
Description, brief – see detailed specifications
Risk Factor
in Q1 with
Risk Factor Present
RF01
Age >=55
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_______
RF02
Male
_______
RF30
Any cancer except basal or squamous-cell skin cancer
_______
RF31
Cirrhosis or chronic hepatitis
_______
RF32
Stroke or transient ischemic attack
_______
RF33
Congestive heart failure
_______
RF34
Kidney disease
_______
RF35
Suspected or documented HIV
_______
RF36
COPD (definition differs from RF11)
_______
ALREADY IDENTIFIED AS NOT FEASIBLE WITH ADMINISTRATIVE DATA
RF37
Inability to take oral medications
_______
ALREADY IDENTIFIED AS NOT FEASIBLE WITH ADMINISTRATIVE DATA
RF38
Temperature below 35°C (95°F) or above 40°C (104°F)
_______
ALREADY IDENTIFIED AS NOT FEASIBLE WITH ADMINISTRATIVE DATA
RF39
Altered mental status
_______
RF41
Sodium below 130 mEq/L
_______
RF42
Hematocrit less than 30%
_______
RF43
Pleural effusion
_______
RF44
Septicemia
_______
RF45
Respiratory failure
_______
2008 Leapfrog Hospital Quality and Patient Safety Survey
2008 New Measures
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CMS HACs – Pressure Ulcers and Hospital-Acquired Injuries
Two hospital-acquired conditions (HACs) that CMS will no longer reimburse hospitals for will be
added to the 2008 Survey. The measurement specifications for calculating rates for these two
conditions - pressure ulcers and hospital-acquired injuries - are as follows:
CMS HAC-1: Rate of Pressure Ulcers
Source: The Leapfrog Group
Numerator: Number of occurrences with an ICD-9 code in a secondary diagnosis field in the ranges: 800829, 830-839, 850-854, 925-929, 940-949, 991-994
Denominator: Total inpatient days
Exclusions:
 Present on admission (POA) indicator for the condition indicates that the condition was present at
admission
 Patients who are less than 18 years of age
CMS HAC-2: Rate of Hospital-Acquired Injuries
Source: The Leapfrog Group
Numerator: Number of occurrences with an ICD-9 code in a secondary diagnosis field of 707.00, 707.01,
707.02, 707.03, 707.04, 707.05, 707.06, 707.07, 707.09
Denominator: Total inpatient days
Exclusions:
 Present on admission (POA) indicator for the condition indicates that the condition was present at
admission
 Patients who are less than 18 years of age
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