The Leapfrog Hospital Survey
Hard Copy
Questions, Reporting Periods, and Endnotes
Welcome to the 2014 Leapfrog Hospital Survey
For background information about the Leapfrog Hospital Survey, including Fact Sheets,
Bibliographies, and White Papers, please visit www.leapfroghospitalsurvey.org and look in the
‘About the Survey’ section.
Important ‘Housekeeping’ Notes about the 2014 Survey
1. The survey homepage is located at www.leapfroghospitalsurvey.org. After logging in to the online
survey with your 16-digit security code, you will be taken to the survey dashboard. The survey
dashboard includes buttons for:
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PROFILE – The profile page includes all of the information in Section 1 of the Leapfrog Hospital
Survey. Certain fields on the profile page will be pre-populated, but all of the fields are editable so
that you can update your hospital name, address, Medicare Provider Number, CEO, survey
contact, and other information at any time.
ONLINE SURVEY – Once you complete and save the profile page, the Online Survey button will
appear on the dashboard. By selecting the Online Survey button, you will be able to access
Sections 2-9 of the Leapfrog Hospital Survey.
CPOE EVALUATION TOOL – If your hospital has implemented CPOE and you would like to
access the CPOE Evaluation Tool, you must first (a) complete Section 2 of the survey, (b) affirm
Section 2 of the survey, and (c) submit Section 2 of the survey. You can log back in to the survey
to complete the remaining sections of the survey (3-9) at any time.
PRINT LAST SAVED SURVEY – Generates a PDF document that includes any responses that
have been entered and saved.
PRINT LAST SUBMITTED SURVEY – Generates a PDF document that includes any responses
that have been submitted. As a reminder, a section must be completed and affirmed, before it can
be submitted.
DETAILS – After July 25th, when Leapfrog publishes the first Leapfrog Hospital Survey Results
on its public reporting website, www.leapfroggroup.org/cp, hospitals will be able to access the
details page from the dashboard. The details page includes information about resource use
scoring, survival predictor scoring, and safe practice scoring that is not published.
PRINT 2013 LAST SUBMITTED SURVEY – Generates a PDF document that includes questions
and responses that were submitted to the 2013 Leapfrog Hospital Survey by December 31, 2013.
This document only includes responses from sections of the survey that were affirmed and
submitted.
2. A Quick Start Guide providing users with information on the online tool updates can be found under
‘Quick Links’ on the survey home page. Please review the Quick Start Guide for important information
regarding how to navigate the online survey.
3. The online survey and CPOE Evaluation Tool performs best when opened in Internet Explorer (IE) 9.
However, the online survey tool and CPOE Evaluation Tool are also compatible with IE 8.
4. All 16-digit security codes from the 2013 survey are still valid. Use just the 16-digit security code to
access your survey. If you no longer have a valid 16-digit security code, see the home page of the online
survey for more information about getting a security code.
5. The 2014 Leapfrog Hospital Survey will close on December 31, 2014. Hospitals that do not submit
a survey by December 31, 2014 will have to wait until the launch of the 2015 survey in April 2015 to
submit a survey.
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Updated Release: October 23, 2014
What's New in the 2014 Survey (Version 6.1)
The content changes to the prior year’s survey (2013 v 6.0) are as follows:
SECTION
1
BASIC HOSPITAL
INFORMATION
(PROFILE)
2
COMPUTERIZED
PHYSICIAN ORDER
ENTRY (CPOE)
3
EVIDENCE-BASED
HOSPITAL
REFERRAL
UPDATE
The Leapfrog Group will ask hospitals to “opt-out” if they do not want their
contact information shared with a third party. The contact information that could
be shared includes: CEO name, survey contact name, survey contact title,
survey contact email address, survey contact phone number, system contact
name, and system contact email address.
The Leapfrog Group has extended the amount of time hospitals have to
complete steps 4 and 5 of the CPOE Evaluation Tool (i.e., enter the orders,
record advice/information, enter final results, and submit results). Previously,
hospitals were allowed 2 hours to complete steps 4 and 5. Hospitals will now
have 2.5 hours to complete steps 4 and 5, with a 30-minute time limit for step 5.
Hospitals will continue to have 4 hours to complete steps 1-3. For more
information on the CPOE Evaluation Tool, visit
https://leapfroghospitalsurvey.org/cpoe-evaluation-tool/.
Section 3B: Removal of SCIP-Card 2 Process Measure from Abdominal Aortic
Aneurysm (AAA) Repair
Over the past several years, the number of AAA’s repaired via endovascular
procedures have significantly increased. These endovascular procedures are
typically lower risk than traditional open repair, and the importance of beta
blockers has not been well studied within this group of patients. Therefore,
Leapfrog will remove the perioperative beta blocker for AAA patients on beta
blockers prior to arrival (AAA-1) from Section 3B. Hospitals will be simply scored
on the predicted survival of patients undergoing this procedure at their hospital.
The AAA scoring algorithm will mirror how hospitals are scored on the
Pancreatectomy and Esophogectomy subsections of the survey.
Section 3E: Change in Antenatal Steroid Measure for High-Risk Newborn
Deliveries
For several years, Leapfrog has given hospitals two options when reporting on
the administration of antenatal steroids to women prior to delivery of very low
birth-weight babies: (1) hospitals could report data submitted to the Vermont
Oxford Network or (2) use Leapfrog’s measure specifications, which closely align
with the Vermont Oxford Network. Beginning in 2014, Leapfrog will replace the
second option (Leapfrog’s own measure specifications) with the Joint
Commission’s PC-03 Antenatal Steroids measure. Hospitals will continue to have
the option of reporting data submitted to the Vermont Oxford Network.
4
MATERNITY CARE
Page 3
The scoring algorithm for this section will remain unchanged. The target for all
hospitals on the antenatal steroid measure will remain 80% or greater
adherence.
Addition of NTSV Cesarean Section Measure
All hospitals reporting at least 50 births annually will be asked to provide their
NTSV cesarean section delivery data on the Maternity Care section. Leapfrog
will collect hospital responses to the new NTSV cesarean section delivery
measure and score hospitals accordingly. However, individual hospital rates will
not be publicly reported on the Leapfrog’s Hospital Survey Results website until
2015. In 2014, hospitals will only be able to view their results for this measure on
their password-protected “Details” page.
In 2015, Leapfrog plans to publicly report individual hospital results on the NTSV
cesarean section delivery rate measure on the Leapfrog Hospital Survey Results
website.
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Updated Release: October 23, 2014
5
ICU PHYSICIAN
STAFFING
6
NQF SAFE
PRACTICES
7
MANAGING
SERIOUS ERRORS
8
SAFETY-FOCUSED
SCHEDULING
9
RESOURCE USE
FOR COMMON
ACUTE
CONDITIONS
Leapfrog will expand hospital’s opportunity to earn partial credit on the IPS
standard if the hospital has physicians certified in critical care medicine
managing or co-managing ICU patients for at least 4 hours per day, 7 days per
week. The physicians providing this care must be ordinarily present on-site in
these units and provide clinical care exclusively in one ICU during these hours.
The 4 hours per day, 7 days per week coverage will be an alternative to the
historical 8 hours per day, 4 days per week coverage that has offered hospitals
the opportunity for partial credit.
Since introducing the NQF Safe Practices to the Leapfrog Hospital Survey in
2004, Leapfrog has asked hospitals if they conduct a safety and quality survey of
units using a nationally recognized tool. Given research that shows a link
between performance on specific domains on culture of safety surveys and
better patient outcomes, Leapfrog is interested in better understanding which tool
hospitals are using to measure their culture of safety. At the end of the Safe
Practices section, hospitals are asked to provide information about the culture of
safety instrument they are using; information that will be used to inform future
survey questions.
For the past several years, Leapfrog has asked hospitals to report on their rates
of hospital-acquired infections. Currently, most hospitals are collecting and
reporting data on central-line associated blood stream infections and catheterassociated urinary tract infections in ICUs through CDC/NHSN for CMS’ Inpatient
Quality Reporting Program. As these data cannot accurately be collected
retrospectively, Leapfrog will remove the measures specifications for both HAIs
from the Leapfrog Hospital Survey Reference Book. Hospitals can continue to
report their data to the Leapfrog Hospital Survey as collected for and submitted
to CDC/NHSN.
For this section, Leapfrog has asked hospitals to report on the utilization of
operating rooms that service inpatients, with a target of 85% utilization. This
year, Leapfrog is adding a set of questions that focuses on a patient’s access to
the operating room by urgency level (i.e., urgent, emergent, scheduled) by
surgical service. The goal of these new questions is to ensure that hospitals are
achieving appropriate utilization rates without sacrificing patient access. These
results will not be publicly reported until 2015.
In 2013, Leapfrog added a series of questions based on volume and readmission
rates reported by CMS for three common acute conditions: AMI, Heart Failure,
and Pneumonia. At that time, critical access hospitals were not able to access
these questions in the online survey. In 2014, critical access hospitals that
voluntarily reported 30-day risk standardized readmission rates for AMI, Heart
Failure, and/or Pneumonia to CMS will be able to complete these questions on
the online Leapfrog Hospital Survey. Critical access hospitals that do not
voluntarily report this information to CMS will continue to be scored as “Does Not
Apply.”
Additional Information for Hospitals Submitting a 2014 Survey
1. Only the hospital’s organizational and contact information from the 2013 survey is retained in the
online survey. Review your hospital’s profile and update as needed. Hospitals are required to enter
new responses and then review, affirm and submit their survey responses by June 30, 2014.
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 more details on the desk review process,
please see: (https://leapfroghospitalsurvey.org/about-the-survey/)
In addition to the desk reviews, Leapfrog has asked randomly selected hospitals to provide
documentation related to their submitted responses. Given the recent use of the Leapfrog Hospital
Survey data by high-visibility data licensees, we do encourage hospitals to be extra careful in
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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. Hospitals that submit a Leapfrog Hospital Survey by the June 30, 2014 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 2014
Leapfrog Hospital Survey responses. The LHRP Summary Reports are mailed to the hospital CEO
provided by your hospital in the profile 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 New Jersey, health care payers have licensed the Leapfrog Hospital Recognition Program and
offer further recognition and rewards to hospitals that participate in the Leapfrog Hospital Survey. To
be eligible for recognition or rewards in these hospital markets, hospitals must submit a survey by
June 30, 2014 and an updated survey between September 1, 2014 and December 31, 2014. For
questions or more information, please contact helpdesk@leapfroggroup.org.
4. 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 profile
section of the survey. If the notification is sent before your hospital submits a 2014 Leapfrog Hospital
Survey, the e-mail will go to the survey contact provided in the last survey submitted in the 2013
survey cycle.
5. The signed affirmation at the end of each section of the survey is used as a check to ensure hospitals
are submitting accurate responses to the survey. The affirmation language at the end of each section
reflects that the affirmation needs to be completed by the hospital CEO or by an employee of
the hospital to whom the hospital CEO has delegated responsibility.
How Leapfrog Uses the Survey Results
Leapfrog’s purchaser members use the survey responses to (1) educate and inform enrollees about
patient safety and the importance of comparing provider performance on Leapfrog’s safety, quality, and
resource standards and (2) recognize and reward providers that have met the standards. This means that
purchasers will share the survey results with their employees and use the survey results in their
contracting discussions with health plans and providers. The Leapfrog Group will share the results from
all hospitals with the public on its website (www.leapfroggroup.org/cp). The Web display of hospitals’
results is made available to aid consumers in their decisions about where to receive care. External
organizations that wish to use the data, for other purposes such as consumer education tools, market
analysis, or contracting decisions, must license the data from The Leapfrog Group for a fee. The revenue
from data licenses is used to support the ongoing administration of the Leapfrog Hospital Survey and
Leapfrog’s data dissemination efforts. For those hospitals that choose not to respond to a request to
complete the survey, the publicly reported survey results will read: “Declined to Respond.”
Leapfrog recognizes the highest performers on the Leapfrog Hospital Survey through its annual Top
Hospital designation. Top Hospital awards are given in three categories: Top Urban Hospitals, Top Rural
Hospitals, and Top Children’s Hospitals. To be considered for a Top Hospital award, hospitals must
submit a survey by August 31, 2014. Hospitals receiving the award are notified in late October, and are
announced publicly at Leapfrog’s Annual Meeting in December. The criteria for the Top Hospital award
are determined each year by a committee evaluating hospital performance across all areas of the
Leapfrog Hospital Survey. For more information, please visit www.leapfroggroup.org/TopHospitals.
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Accessing the Online Survey
Leapfrog’s efforts have a special focus on acute-care adult and pediatric facilities around the country. If
your hospital is located in one of Leapfrog's current “Regional Roll-Out” areas, your hospital CEO/chief
administrative officer should have received an introductory letter requesting your hospital’s participation in
the survey and containing a security code for completing the survey online.
Leapfrog Group’s current Roll-Out Regions
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Arizona
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Maine
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Maryland
Massachusetts
Missouri
Nevada - Southern
New Hampshire
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California
Colorado
Connecticut
District of Columbia
Florida –
Central/Southern/Tampa
Georgia – Savannah
Illinois
Indiana - Northern/Central
Indiana – Southern
Pennsylvania – Greater
Philadelphia
South Carolina
Tennessee – East/Mid
Tennessee - Memphis/West
Washington – Seattle
Texas – Dallas/Fort Worth
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Virginia
Washington – Seattle
Virginia
Wisconsin
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Iowa
Kentucky
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New Jersey
New York City (Metro
New York State (not NYC)
North Carolina Raleigh/Durham/Chapel Hill
Ohio
Pennsylvania – Lehigh Valley
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Wyoming
Go to the ‘Get a Security Code’ page of the online survey for more information about the geographic
areas covered by these regions, regional contacts, and getting a security code needed to complete the
online survey.
If you are a free-standing pediatric or general acute-care hospital, and you are located outside of one of
the Roll-Out Regions, a letter requesting your hospital’s participation in the survey and containing a
security code for completing the survey online will come directly from The Leapfrog Group.
The Leapfrog Group also invites all hospitals nationwide to complete the survey and share their progress
and plans with their communities. If your organization is not located in one of the Regional Roll-Out areas,
or did not receive a security code in the mail from Leapfrog, but would like to complete the survey, you
can request an ID and security code on the ‘Get a Security Code’ page of the online survey.
If you have any questions, please use the Help Desk link on the home page of the survey site indicated
above.
Overview of the 2014 Leapfrog Hospital Survey
The Leapfrog Hospital Survey is divided into nine sections. The first section (Profile) asks you to provide
general information about your hospital. Sections Two, Three, Five, and Six are designed to determine
whether or not your hospital has fully implemented or plans to implement fully The Leapfrog Group’s
original quality and safety practices (Leaps), including: Computerized Physician Order Entry, EvidenceBased Hospital Referral, ICU Physician Staffing, and eight of the National Quality Forum Safe Practices.
Section four is designed to demonstrate a hospital’s performance on nationally endorsed maternity
measures of care. Section seven is designed to demonstrate hospital’s performance in preventing
hospital-acquired infections and conditions. Sections Eight and Nine are designed to reflect how
judiciously hospitals utilize their resources.
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Each of these sections has the same format:
1. General discussion about The Leapfrog Group standard for that area [in the hardcopy only]. Where
appropriate, there are references that provide more detailed information about each standard and
other information that you may need to complete the survey questions.
2. Survey questions that indicate your organization’s status vis-à-vis implementing each standard.
3. Affirmation of accuracy by your hospital’s CEO/ chief administrative officer or by an individual that has
been designated as a delegate by the hospital CEO. These statements affirm the accuracy of the
description of your hospital’s current practices or plans.
The Leapfrog Group is committed to presenting information that is as current as possible. Leapfrog and
its participating members will use your responses to describe to the public the progress that your hospital
is making toward implementing the Leapfrog safety, quality, and resource use standards. You can visit
this survey site at any time to review your responses or update them as needed. We update the public
display (www.leapfroggroup.org/cp) of survey results monthly, July through January, and results from
your survey (re)submissions will appear on the site in the first week of the following month. We invite you
to update the information in this survey within 60 days of any change in status. We reserve the right either
to omit or have disclaimers accompany information that is not current.
If you have additional questions about this survey or The Leapfrog Group, please visit
http://www.leapfroggroup.org or contact the Help Desk at
https://leapfroghospitalsurvey.zendesk.com/home.
Completing and Submitting the Survey
Visit https://www.leapfroghospitalsurvey.org. Please review a copy of the Quick Start Guide before
logging on to the online survey tool for the first time. The Quick Start Guide is located under ‘Quick Links’
on the survey website.
Submitting this survey will require a number of steps:
1. Download a hard copy of the survey in the “Download Survey Materials’ section of the website. Read
through the entire survey to ensure that you understand what information is required.
2. Review background information about The Leapfrog Group’s quality and safety standards. There are
fact sheets and bibliographies of the pertinent medical literature for each of the standards at
www.leapfroghospitalsurvey.org in the ‘About the Survey’ section.
3. Download the Leapfrog Hospital Survey Reference Book and other supporting documentation in the
‘Download Survey Materials’ section of the website. These documents contain important measure
specifications and instructions that hospitals will need to respond to the survey questions.
4. For Section 6 (the NQF Safe Practices), review the NQF’s Safe Practices for Better Healthcare 2010
Update, and have a copy of the full report accessible for cross-reference as you complete that
section. You can download a copy of the full report using the link available in the ‘Download Survey
Materials’ section of the website.
5. This survey requires information that you might not have readily available. We recommend that you
print and review a hard copy of the survey and reference book (which contains the measure
specifications for each question), then assign the survey completion to others in your organization as
appropriate. It is important that all individuals helping you collect responses review any additional
information, including tools and calculators, available at www.leapfroghospitalsurvey.org. This might
include someone from your quality department who regularly compiles data, as well as
representatives from your IT group or medical staff. Hospitals that test Leapfrog’s survey suggest it
might take anywhere from 5-7 days to gather these data depending on the number of people involved
and the ease of access to statistical or audit data needed for some questions.
6. When printed, endnotes referenced throughout the survey can be located at the end of the survey.
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7. As the survey information is collected, it should be marked on a hardcopy of the survey. This will
expedite the online completion and avoid the survey "timing out" after 20 minutes of idle time (a
security precaution). Once all information has been collected, the CEO/chief administrative officer or
his/her designated respondent(s) can typically complete the survey online in less than 90 minutes
from the hardcopy record.
8. Responses can only be submitted through the online survey tool. Hardcopy or faxed submissions are
not accepted.
9. Each section of the survey (Sections 2-9) ends with an Affirmation of Accuracy that must be
completed. Only sections that are complete and affirmed can be submitted. Sections that are
complete, but not affirmed, cannot be submitted.
10. The online survey tool allows users to enter individual responses to questions, save those responses,
and come back in at another time to finish a survey section. At the bottom of each section are three
navigation buttons. The three navigation buttons and a brief description of each one are as follows:
Button
Clear Subsection
Description
Clears all data from the current page (section/subsection).
Save Responses and Exit
Saves entered data in all sections and logs the user out of
the survey.
Submit Sections, Save Others
Submits survey sections which have been completed and
affirmed; saves all other entered data.
If survey responses are updated, remember to re-affirm the section in which updates were made
and re-submit the entire survey.
11. Separate sections can be completed online at different times, by different users, in different (nonconcurrent) online sessions. Once all necessary sections are completed and affirmed, the entire
survey must then be submitted so it can be scored and publicly reported by Leapfrog each month.
Make sure to submit your hospital’s survey results after completing or updating the survey.
Always print a copy of your “Last Submitted Survey” to review for accuracy and
completeness.
12. To access the CPOE Evaluation Tool, please find information, including a detailed set of instructions
at https://leapfroghospitalsurvey.org/cpoe-evaluation-tool/. Please note: Hospitals must first complete,
affirm, and submit Section 2 CPOE before they are able to access the Tool. Hospitals can return to
complete and submit the remainder of the survey (Sections 3-9) at any time.
13. Note the word “hospital” used throughout this survey refers to an individual hospital. If your hospital is
part of a multi-hospital healthcare system, you will need to complete the survey for each individual
hospital within the system. Please refer to Leapfrog’s Multi-Campus Hospital Reporting Policy at
https://leapfroghospitalsurvey.org/web/wp-content/uploads/multicampus.pdf.
14. If you have any questions, please use the Help Desk link at the bottom of the home page of the
survey site at https://www.leapfroghospitalsurvey.org. Most questions submitted to the Help Desk will
receive a response within one business day.
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Basic Hospital Information
2014 Leapfrog Hospital Survey
Section 1: Basic Hospital Information
Organization Information
If your hospital is part of a larger healthcare system, you should respond to this survey for your individual
hospital only. Your hospital has been identified based on its separate designation as a Medicare-certified
hospital. (If your hospital was not included in the roster derived from the Medicare Provider of Service
directory, you have been assigned a special identification number for the purposes of completing this
survey only.)
Your responses should reflect the status and information pertaining only to this hospital, as identified. If
you are responding on behalf of a multi-hospital system, separate survey responses are required for each
hospital based on their separate Medicare certification (or the special identifier assigned to your hospital).
1)
Hospital name
(make any necessary corrections online)
2)
3)
4)
5)
6)
7)
Street address
City
State1
ZIP code
Main phone number
Hospital’s Medicare Provider Number (MPN)2
8)
Hospital Website address
(So consumers can learn more about your hospital’s
efforts in the area of patient safety and quality
improvement.) Tips for entering Web addresses3
9)
Number of licensed4 medical, surgical, and obstetric
beds.
Number of staffed5 medical, surgical, and obstetric beds.
Number of total acute-care admissions6 to your hospital
for most recent 12 months available.
Number of licensed ICU7 beds.
Number of staffed ICU8 beds.
Number of admissions to adult and pediatric general
medical/surgical ICU(s)9 for most recent 12 months
available.
Is this hospital part of a healthcare system or Integrated
Delivery Network (IDN)?
If so, please enter the name of the healthcare system or
IDN.
Is your hospital a member of the Council of Teaching
Hospitals and Health Systems (COTH)?10
10)
11)
12)
13)
14)
15)
16)
17)
18) If no, is your hospital considered a teaching hospital?11
Yes
No
Yes
No
Yes
No
19) Hospital's federal tax identification number12 (TIN)
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Basic Hospital Information
2014 Leapfrog Hospital Survey
Contact Information
1) Name of Chief Executive Officer of your hospital
2) CEO’s e-mail address (optional)
3) Name of Chairman of Board of your hospital
4) Name of contact person for this survey
5) Contact’s title
6) Contact's phone number
7) Contact's e-mail address
If this hospital is part of a healthcare system or Integrated Delivery Network (IDN), you may optionally
indicate a contact person at the system level to be included in communications about your hospital’s
survey.
8) Name of system contact for this survey
9) System contact’s e-mail address
Leapfrog may need to contact your hospital’s public relations department (e.g., if your hospital is chosen
as a Leapfrog Top Hospital).
10) Name of public relations contact at your hospital
11) Public relations contact’s phone number
12) Public relations contact’s e-mail address
13) Opt-out from having information provided in the “Contact
Information” subsection shared with third-parties.
 Opt-out
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Computerized Physician Order Entry
2014 Leapfrog Hospital Survey
Section 2: 2014 Computerized Physician Order Entry (CPOE) Standard
(Results are shown on Leapfrog’s consumer site as “Doctors order medications through a
computer”)
Link to CPOE Fact Sheet: https://leapfroghospitalsurvey.org/web/wp-content/uploads/FScpoe.pdf
Note: The Pediatric Inpatient CPOE Evaluation Tool is not available. Pediatric Hospitals should
complete Q1 and Q2 only.
Each hospital fulfilling this standard:
1. Assures that prescribers* enter at least 75% of inpatient medication orders via a computer system
that includes decision support software to reduce prescribing errors; and,
2. For adult and general hospitals, demonstrates, via a test**, that its inpatient CPOE system can
alert physicians to at least 50% of common serious prescribing errors in a majority of medication
checking categories, including the drug:drug and drug:allergy checking categories.
* “Prescribers” used throughout this section refers to all clinicians authorized by the hospital to order
pharmaceuticals for patients.
** For the 2014 survey, scored results on the Adult Inpatient CPOE Evaluation Tool will be used to assess
if an adult or general hospital’s CPOE system is alerting physicians to at least 50% of common serious
prescribing errors in a majority of medication checking categories, including the drug:drug and
drug:allergy checking categories. A hospital may access the CPOE Evaluation Tool only after indicating
that your hospital has a functioning CPOE system in at least one inpatient unit of the hospital
(answered ‘yes’ to Q1 below). Then, use the link on the survey home page to access the CPOE
Evaluation Tool. Follow the detailed instructions there about how to conduct a test. Once you have
completed a test appropriate to your hospital, the score of the completed test will be used automatically to
determine whether your hospital meets criterion #2 above and what level of credit your hospital has
earned in the overall scoring of this Leap.
Reporting Time Period: Answer questions #1-2 for the latest 3 months prior to submitting this section of
the survey.
1) Does your hospital have a functioning CPOE system in at least one inpatient
unit of the hospital?
If yes, continue with questions 2 and 3; otherwise, skip to Affirmation of Accuracy
2) What percent of your hospital’s total inpatient medication orders (including
orders made in units which do NOT have a functioning CPOE) do prescribers
enter via a CPOE system that:
 includes decision support software to reduce prescribing errors; and,
 is linked13 to pharmacy, laboratory, and admitting-discharge-transfer (ADT)
information in your hospital
Yes
No
_____%
If you answered Yes to question 1, indicating that your hospital has a functioning CPOE system in at
least one inpatient unit, and you are an adult or general hospital, you will be able to evaluate your CPOE
system using the Leapfrog CPOE Evaluation Tool, accessible from the survey dashboard. .
No answer required
3) What was your hospital’s score when it tested its CPOE
Determined automatically based on
system using the Leapfrog CPOE Evaluation Tool?
Test must be completed on or after April 1, 2014.
separately completing a test using the
Leapfrog CPOE Evaluation Tool
Page 11
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Updated Release: October 23, 2014
Computerized Physician Order Entry
2014 Leapfrog Hospital Survey
Affirmation of Accuracy
As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Computerized Physician Order Entry
(CPOE) Standard at our hospital, and I hereby certify that these statements are true, accurate, and reflect
the current, normal operating circumstances at our hospital. I am authorized to make this certification on
behalf of our hospital.
The hospital and I understand that The Leapfrog Group, its members and the public are relying on the
truth and accuracy of this information. The hospital and I also understand that The Leapfrog Group will
make this information and/or analyses of this information public through the survey results public
reporting website, The Leapfrog Group’s Hospital Safety Score, and/or other Leapfrog Group products
and services. This information and/or analyses and all intellectual property rights therein shall be the sole
and exclusive property of The Leapfrog Group. The hospital and I acknowledge that The Leapfrog Group
may use this information in a commercial manner for profit. The hospital shall be liable for and shall hold
harmless and indemnify The Leapfrog Group from any and all damages, demands, costs, or causes of
action resulting from any inaccuracies in the information or any misrepresentations in this Affirmation of
Accuracy. The Leapfrog Group and its participants reserve the right to omit or disclaim information that is
not current, accurate or truthful.
Affirmed by _____________________, the hospital’s ___________________________,
(name)
(title)
on _______________________.
(date)
Page 12
Version 6.1
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Updated Release: October 23, 2014
Evidence-Based Hospital Referral
2014 Leapfrog Hospital Survey
Section 3: 2014 Evidence-Based Hospital Referral (EBHR) Standards
Link to EBHR Fact Sheet: https://leapfroghospitalsurvey.org/web/wp-content/uploads/FSebhr.pdf
Note: This section is not applicable to Pediatric hospitals.
Each hospital fulfilling one or more of the high-risk surgical standards:
1. For aortic valve replacement (AVR), participates in and scores better than the group average for
participating hospitals in its ratio of observed-to-expected mortality in a national performance
measurement system1, or in a regional performance measurement system2, and achieves the
favorable volume characteristic: 120 or more patients/year for the hospital.
or
2. For AVR, abdominal aortic aneurysm repair (AAA), pancreatic resection, and esophagectomy, places
in the best quartile for the predicted mortality composite measure for the procedure, as compared to a
national sample of hospitals.
Each hospital fulfilling the High-Risk Deliveries standard:
1. Achieves favorable hospital volume characteristics for high-risk deliveries by admitting 50 or more
very-low birth-weight newborns/year to its NICU or achieves favorable outcomes for high-risk
deliveries as measured by the Vermont Oxford Network.
and
2. Achieves 80% or higher adherence to nationally endorsed process measure of quality. (See the
Process Measure Specifications in Section 3 of the Leapfrog Hospital Survey Reference Book,
link available on the ’Download Survey Materials’ page of the online survey.)
For hospitals that do not perform these procedures or treat these high-risk deliveries, or refer/transfer all
safely and legally transferable patients for such high-risk procedures or conditions, the standard does not
apply for that procedure or condition. If you answer ‘No’ to any of the procedures listed in questions 1-4
below, the notation ‘Does Not Apply’ will be displayed for that procedure on the public website.
1
2
Society of Thoracic Surgeons (STS)
Northern New England Cardiovascular Disease Study Group (NNECDSG)
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Evidence-Based Hospital Referral
2014 Leapfrog Hospital Survey
EBHR: High-Risk Surgical Procedures Provided
Does your hospital perform these procedures on an elective basis?
If your hospital does not perform the procedure or ONLY does so when a patient is too unstable
for safe transfer, answer ‘No.’
Yes
No
Yes
No
Yes
No
Yes
No
1) Aortic valve replacement
2) Abdominal aortic aneurysm repair
3) Pancreatic resection
4) Esophagectomy
See Volume Standards in Section 3 of the Leapfrog Hospital Survey Reference Book (link found on the
‘Download Survey Materials’ page of the online survey) for ICD-9 coding specifications and other criteria
to identify and count patients with these procedures.
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Evidence-Based Hospital Referral
2014 Leapfrog Hospital Survey
3A: Aortic Valve Replacement
(Results are shown on Leapfrog’s consumer site as “Aortic Valve Replacement”)
If you answered 'yes' to #1 on page 14, complete these questions pertaining to this high-risk surgery.
Aortic Valve Replacement (AVR) – Volume
Specifications: See AVR Volume Standards in Section 3 of the Leapfrog Hospital Survey Reference
Book (link found on the ‘Download Survey Materials’ page of the online survey).
Reporting Time Period: Answer questions #1-3 for the 12-month or, optionally, the 24- month time
period ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
1) Total number of patients (including those that expired) with an AVR procedure
at this hospital location.
Annual number of patients for the volume Reporting Time Period
(or annual average if reporting 24 months of data)
2) Total number of patients (including those that expired) with a Transcatheter
Aortic Valve Replacement (TAVR) procedure at this hospital location.
Annual number of patients for the volume Reporting Time Period (or an
annual average if reporting 24 months of data)
3) How many patients included in question 1 and question 2 died in the hospital
following this procedure? (More information14)
(annual average if 24 months of data)
_______
_______
Aortic Valve Replacement – National Performance Measurement
Indicate your hospital’s participation in and results from the following national performance measurement
system.
Reporting Time Period: Base your responses on the latest 12-month report received from the Society
of Thoracic Surgeons (STS).
4) Has your hospital participated in the Society of Thoracic Surgeons (STS)
performance reporting system for aortic valve replacement surgery and
submitted data for all such procedures in the most recent 12-month
period for which performance reports have been released? More
Information15
If Yes, continue with questions #5-7.
If “Prefer not to share results”, complete question #5 and skip questions
#6 and #7.
Otherwise, skip questions #5-7.
5) What is the most recent 12-month reporting period for which STS
performance results are available? 12 months ending:
Yes
No
Participating but no
reports yet available
Reports available but
prefer not to share
results
__________
MM/YYYY
e.g. 12/2013
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Evidence-Based Hospital Referral
2014 Leapfrog Hospital Survey
6) From the report for that time period, what was the Operative Mortality,
Risk-adjusted rate16 reported for your hospital (observed rate) as a
percentage for aortic valve replacement surgery?
Enter as percent with one decimal-place precision.
7) From the same report, what was the Operative Mortality, Risk-adjusted
rate17 reported for the All STS cohort (expected rate) as a percentage for
aortic valve replacement surgery?
Enter as percent with one decimal-place precision.
_______%
(e.g. 3.1)
_______%
(e.g. 4.2)
Aortic Valve Replacement (AVR) – Regional Registries
Hospitals in Maine, New Hampshire, and Vermont ONLY. If you did not answer question #4 as
“Yes”, please complete questions #8-12.
All other hospitals skip questions #8-12.
Reporting Time Period: Base your responses on the latest 12-month report received from your
regional registry [Northern New England Cardiovascular Disease Study Group (NNECDSG)],
8) Are AVR mortality outcomes for your hospital included in the regional
registry (NNECDSG) report for the most recently reported period18?
If no, skip questions #9-12.
.
9) What is the most recent 12-month reporting period for which your
hospital’s results are included in your regional registry report? 12 months
ending:
Yes
No
__________
MM/YYYY
e.g. 12/2013
10) If AVR mortality outcome results for your hospital are included with another hospital and/or reported
under a different hospital name from that indicated in the Organization Information section of this
survey, indicate the reported name of the hospital:
11) From the report for that time period, what was the observed mortality
rate19 as a percentage for aortic valve replacement surgery?
Enter as percent with one decimal-place precision.
_______%
12) From the same report, what was the expected mortality rate20 as a
percentage for aortic valve replacement surgery?
Enter as percent with one decimal-place precision.
_______%
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(e.g. 3.1)
(e.g. 3.1)
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Updated Release: October 23, 2014
Evidence-Based Hospital Referral
2014 Leapfrog Hospital Survey
3B: Abdominal Aortic Aneurysm (AAA) Repair
(Results are shown on Leapfrog’s consumer site as “Abdominal Aortic Aneurysm Repair”)
If you answered 'yes' to #2 on page 14, complete these questions pertaining to this high-risk surgery.
Abdominal Aortic Aneurysm (AAA) Repair – Volume
Specifications: See AAA Volume Standards in Section 3 of the Leapfrog Hospital Survey Reference
Book (link found on the ‘Download Survey Materials’ page of the online survey).
Reporting Time Period: Answer questions #1-3 for the 12-month or, optionally, the 24- month average
for the time period ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
1) Total number of patients (including those that expired) with an AAA Repair
procedure at this hospital location.
Annual number of patients for the volume Reporting Time Period
(or annual average if reporting on 24 months of data)
2) Total number of patients (including those that expired) with an unruptured
AAA Repair procedure at this hospital location
Annual number of patients for the volume Reporting Time Period
(or annual average if reporting on 24 months of data)
3) How many patients included in question 2 died in the hospital following this
procedure? (More information)14
(annual average if reporting on 24 months of data)
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_______
_______
First Release: April 1, 2014
Updated Release: October 23, 2014
Evidence-Based Hospital Referral
2014 Leapfrog Hospital Survey
3C: Pancreatic Resections
(Results are shown on Leapfrog’s consumer site as “Pancreatic Resection”)
If you answered 'yes' to #3 on page 14, complete these questions pertaining to this high-risk surgery.
Pancreatic Resections – Volume
Specifications: See Pancreatectomy Volume Standards in Section 3 of the Leapfrog Hospital Survey
Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
Reporting Time Period: Answer questions #1-3 for the 12-month or, optionally, the 24- month time
period ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
1) Total number of patients (including those that expired) with a Pancreatic
Resection procedure at this hospital location.
Annual number of patients for the volume Reporting Time Period
(or annual average if 24 months of data)
2) Total number of patients (including those that expired) in question 1 with a
diagnosis of duodenal, biliary, or pancreatic cancer
(annual average if 24 months of data)
3) How many patients included in question 2 died in the hospital following this
procedure? (More information)14
(annual average if 24 months of data)
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_______
_______
First Release: April 1, 2014
Updated Release: October 23, 2014
Evidence-Based Hospital Referral
2014 Leapfrog Hospital Survey
3D: Esophagectomy
(Results are shown on Leapfrog’s consumer site as “Esophageal Resection”)
If you answered “Yes” to #4 on page 14, complete these questions pertaining to this high-risk surgery.
Esophagectomy – Volume
Specifications: See Esophagectomy Volume Standards in Section 3 of the Leapfrog Hospital Survey
Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
Reporting Time Period: Answer questions #1-3 for the 12-month or, optionally, the 24-month time
period ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
1) Total number of patients (including those that expired) with an
Esophagectomy procedure at this hospital location.
Annual number of patients for the volume Reporting Time Period
(or annual average if 24 months of data)
2) Total number of patients (including those that expired) in question 1 with a
diagnosis of esophageal cancer
(annual average if 24 months of data)
3) How many patients included in question 2 died in the hospital following this
procedure? (More information)14
(annual average if 24 months of data)
Page 19
Version 6.1
_______
_______
_______
First Release: April 1, 2014
Updated Release: October 23, 2014
Evidence-Based Hospital Referral
2014 Leapfrog Hospital Survey
3E: EBHR: High-Risk Deliveries
(Results are shown on Leapfrog’s consumer site as “High-Risk Delivery”)
High-Risk Deliveries
1) Does your hospital electively admit high-risk deliveries21?
If “No”, skip remainder of this section, otherwise continue.
Yes
No
2) Does your hospital operate a neonatal ICU, or is it co-located22 with a
hospital that operates a NICU, that admits or accepts transfers of verylow birth weight babies23?
If no, skip to questions #11-13.
Yes
No
If the NICU is co-located in another hospital and your hospital
immediately transfers all complicated newborns there, answer Questions
3 and either 4 or 5-10 based on information pertaining to the co-located
hospital’s NICU.
3) Hospitals that participate in the Vermont Oxford Network (VON), and
have a recent 12-month or 36-month report available, may elect to report
your facility’s Volume (Question #4) OR the VON’s Death or Morbidity
Measure (Questions #5-10). Hospitals that do not participate in the
Vermont Oxford Network, should simply report on Question #4.
Please indicate which measure the hospital will report on:
Volume
If you elect to report on Volume, answer Q4, and skip Q5-10. If you elect to
report on the National Performance Measure, skip Q4, and report on Q5-10.
National Performance
Measure
Neonatal Intensive Care Unit(s) – Volume
Specifications: See High Risk Deliveries Volume Standard in Section 3 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
Reporting Time Period: Answer question #4, if applicable, for the 12-months ending :
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
4) For the Reporting Time Period, how many very-low birth-weight babies
were admitted to your hospital’s neonatal intensive care unit(s)?
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_______
First Release: April 1, 2014
Updated Release: October 23, 2014
Evidence-Based Hospital Referral
2014 Leapfrog Hospital Survey
Neonatal Intensive Care Unit(s) – National Performance Measurement
Specifications: See High Risk Deliveries Outcome Measure in Section 3 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
Reporting Time Period: Base your responses on the latest 12-month or 36-month report received from
the Vermont Oxford Network (VON) for the Death or Morbidity Measure.
5) Has your hospital participated in the Vermont Oxford Network
performance reporting system for high-risk deliveries and submitted data
for all such deliveries in the most recent 12-month period for which
performance reports have been released?
If no, please return to Q3 and select “Volume,” then complete Q4.
6) What is the most recent 12-month or 36-month reporting period for which
VON performance results are available? Time period ending:
Yes
No
__________
YYYY
e.g. 2009
7) From the report for that time period, what is your hospital’s volume?
_______
(e.g. 70)
8) From the same report, what was your hospital’s SMR 95% lower
bound?
Enter as a number with one decimal-place precision.
_______
9) From the report for that time period, what was your hospital’s observed
to expected ratio of morbidity or mortality (SMR shrunken)?
Enter as a number with one decimal-place precision. .
_______
10) From the same report, what was your hospital’s SMR 95% upper
bound?
Enter as a number with one decimal-place precision.
_______
(e.g. 3.1)
(e.g. 4.2)
(e.g. 4.2)
High-Risk Deliveries – Process Measures of Quality
Process Measures of Quality
Indicate your hospital’s adherence to the nationally endorsed condition-specific process measure of
quality regarding antenatal steroids for certain high-risk deliveries, if measured.*
Specifications: See High Risk Deliveries Process Measure Specifications in Section 3 of the
Leapfrog Hospital Survey Reference Book.
Reporting Time Period:
For hospitals reporting on the VON measure, answer questions #11-13 for the most recent 12-month
period available, ending within the last 12-months.
For hospitals reporting on The Joint Commissions PC-03 measure, answer questions #11-13 for the
12-months ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
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Evidence-Based Hospital Referral
2014 Leapfrog Hospital Survey
* Responses may be based on the same data reported to Vermont Oxford Network for this process
measure where those data are available. Data submitted from Vermont Oxford Network should be based
on the most recent report. If data are not submitted to VON, hospitals should measure and report
results as described in the Leapfrog Hospital Survey Reference Book based on the Joint Commissions
PC-03 Antenatal Steroids measure
11) Has your hospital performed a medical record audit on all cases (or a
sufficient sample of them)24 for certain high-risk deliveries for the
Reporting Time Period, and measured adherence to the antenatal
steroids clinical process guideline for these high-risk deliveries.*
If no, skip Q12-13.
If yes, but zero cases met the inclusion criteria for the denominator, skip
Q12-13.
12) Number of cases measured against the guideline, either all cases or the
sample size, for these deliveries, i.e. number of cases audited and
meeting the criteria for inclusion in the denominator of the measure.
13) Number of cases in question 12 that adhere to the clinical process
guideline for this condition (numerator)
Yes
No
Yes, but zero cases met
the inclusion criteria for
the denominator
_______
_______
Affirmation of Accuracy
As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Evidence-based Hospital Referral
(EBHR) Standard at our hospital, and I hereby certify that these statements are true, accurate, and reflect
the current, normal operating circumstances at our hospital. I am authorized to make this certification on
behalf of our hospital.
The hospital and I understand that The Leapfrog Group, its members and the public are relying on the
truth and accuracy of this information. The hospital and I also understand that The Leapfrog Group will
make this information and/or analyses of this information public through the survey results public
reporting website, The Leapfrog Group’s Hospital Safety Score, and/or other Leapfrog Group products
and services. This information and/or analyses and all intellectual property rights therein shall be the sole
and exclusive property of The Leapfrog Group. The hospital and I acknowledge that The Leapfrog Group
may use this information in a commercial manner for profit. The hospital shall be liable for and shall hold
harmless and indemnify The Leapfrog Group from any and all damages, demands, costs, or causes of
action resulting from any inaccuracies in the information or any misrepresentations in this Affirmation of
Accuracy. The Leapfrog Group and its participants reserve the right to omit or disclaim information that is
not current, accurate or truthful.
Affirmed by _____________________, the hospital’s ___________________________,
(name)
(title)
on _______________________.
(date)
Page 22
Version 6.1
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Updated Release: October 23, 2014
Maternity Care
2014 Leapfrog Hospital Survey
Section 4: 2014 Maternity Care
Link to Maternity Care Fact Sheet: https://leapfroghospitalsurvey.org/web/wpcontent/uploads/FSmaternity.pdf
Note: Adult and Pediatric Hospitals that did not deliver newborns during the reporting period
should respond “No” to question 1, and then skip the remainder of the section. The hospital will
be shown as “Does Not Apply.”
This section of the survey addresses the care provided by a hospital for normal newborn deliveries.
Hospital performance in this section is measured by evidence-based outcome and process measures.
Each hospital fully meeting the standards for Maternity Care:
1. Meets or is better than the target for performance on the nationally-endorsed “Elective Deliveries
Before 39 Weeks Gestation” outcome measure
2. Meets or is better than the target for performance on the nationally-endorsed “Incidence of
Episiotomy” outcome measure
3. Meets or exceeds an 80% target for both process measures of care
4. In addition, Leapfrog will calculate an adjusted and unadjusted NTSV C-section rate for hospitals.
However, these results will only be posted on the hospital’s Details page. The results will not be
publicly reported at www.leapfroggroup.org/cp until the 2015 survey cycle.
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Updated Release: October 23, 2014
Maternity Care
2014 Leapfrog Hospital Survey
Maternity Care
Specifications: See Maternity Care Volume Standards in Section 4 of the Leapfrog Hospital Survey
Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
Reporting Time Period: Answer all questions #1 – 2 for the 12 months ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
1) Did the hospital deliver newborn babies during the reporting period?
If no, please skip remaining questions for section 4 including those in
subsections 4A, 4B, 4C, and 4D; hospital will be scored as “Does not apply.”
Otherwise, continue on to question #2.
2) Total number of live births at this hospital location for the Reporting Time Period
If fewer than 10 cases, skip remaining questions for section 4 including those in
subsections 4A, 4B, 4C, and 4D. Otherwise continue to Section 4A, question
#1.
Yes
No
______
4A: Early Elective Deliveries
(Results shown on Leapfrog’s consumer site as “Rate of Early Elective Deliveries”)
Specifications For questions 1 and 2, responses can and should be the same data reported to The
Joint Commission and or the Centers for Medicare and Medicaid, as reported and accepted by those
organizations (recognizing that the reporting time period may be slightly different than what is stated
below).
If data are not submitted to The Joint Commission or to the Centers for Medicare and Medicaid (CMS),
hospitals should measure and report results as described in the Maternity Care Outcome Measure
Specifications in Section 4 of the Leapfrog Hospital Survey Reference Book (link found on the
‘Download Survey Materials’ page of the online survey). Answer questions 1 and 2 based on all cases
(or a sufficient sample* of them) for the Reporting Time Period per the specifications.
Reporting Time Period: Answer questions #1 and #2 based on all cases (or a sufficient sample of
them*) for the 12-months ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
*Sufficient Sample: Instructions for identifying a sufficient sample to answer questions #1 and #2 are
found in the Maternity Care Outcome Measure Specifications in Section 4 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
Page 24
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Updated Release: October 23, 2014
Maternity Care
2014 Leapfrog Hospital Survey
Elective Delivery Prior To 39 Completed Weeks of Gestation
1) Total number of mothers (or sufficient sample of them) that delivered newborns
with >=37 weeks of gestation completed and <39 weeks of gestation completed
during the reporting period, with Excluded Populations removed.
______
For hospitals that participate in the CMS Inpatient Quality Reporting Program (IQR),
please utilize your CMS report for Early Elective Deliveries (IQR-PC) to respond to
the following questions. For hospitals that do not participate in the IQR, the following
questions are optional. Responses to these questions are for informational
purposes only, and will not be used in scoring.
Total number of mothers excluded from the denominator (question 1) due to the
following medical indications:
____
1a) ICD-9 code for medical indication for elective delivery
____
1b) Enrolled in a clinical trial
1c) Prior Uterine Surgery (please be sure to review the data element definition
in Leapfrog Hospital Survey Reference Book)
2) Total number of mothers indicated in question 1 which had their newborn
delivered electively (not spontaneously).
3) Do the responses in Q1 and Q2 above represent a sample of cases?
4) If “yes” to Q3, did your hospital sample using The Joint Commission’s sampling
algorithm or Leapfrog’s sampling instructions, as provided in the Survey
Reference Book?
____
______
Yes
No
The Joint
Commission
The Leapfrog
Group
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Maternity Care
2014 Leapfrog Hospital Survey
4B: Cesarean Section
(Results not shown on Leapfrog’s consumer site. Results available to hospitals ONLY on the
Details page – link in survey dashboard – after July 25, 2014)
Specifications: For questions #1-8, responses can and should be the same data reported to The Joint
Commission, as reported and accepted by that organization (recognizing that the reporting time period
may be slightly different than what is stated below). If data are not submitted to The Joint Commission,
hospitals should measure and report results as described in the Maternity Care Outcome Measure
Specifications in Section 4 of the Leapfrog Hospital Survey Reference Book (link found on the
‘Download Survey Materials’ page of the online survey). Answer questions #1-8 based on all cases (or a
sufficient sample* of them) for the Reporting Time Period per the specifications.
Reporting Time Periods: Answer questions #1-8 based on all cases (or a sufficient sample of them*) for
the 12 months ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
*Sufficient Sample: Instructions for identifying a sufficient sample to answer questions #1-8 are found in
the Maternity Care Outcome Measure Specifications in Section 4 of the Leapfrog Hospital Survey
Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
Instructions
For each of the eight age stratums listed below, indicate in column:
(a) If your hospital had any cases that fell into the particular maternal age stratum.
(b) The number of cases that met the criteria for the denominator; see Maternity Care Outcome
Measure Specifications in Section 4 of the Leapfrog Hospital Survey Reference Book for
details.
If zero, enter “0.” Do not leave blank.
(c) The number of cases that met the criteria for the numerator; see Maternity Care Outcome
Measure Specifications in Section 4 of the Leapfrog Hospital Survey Reference Book for
details.
If zero, enter “0.” Do not leave blank
Maternal Age Stratums
1) Ages 8-14
2) Ages 15-19
3) Ages 20-24
4) Ages 25-29
5) Ages 30-34
Page 26
(a)
Did your hospital
have any cases
that fell into this
maternal age
stratum?
if No, skip (b) & (c)
(b)
# of cases
measured
(c)
# of cesarean
sections
(denominator)
(numerator)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Version 6.1
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Updated Release: October 23, 2014
Maternity Care
2014 Leapfrog Hospital Survey
Yes
No
Yes
No
Yes
No
6) Ages 35-39
7) Ages 40-44
8) Ages 45-54
Yes
No
The Joint Commission
9) Do the responses in Q1-Q8 above
represent a sample of cases?
10) If “yes” to Q9, did your hospital
sample using The Joint
Commission’s sampling algorithm
or Leapfrog’s sampling
instructions, as provided in the
Survey Reference Book?
The Leapfrog Group
4C: Episiotomy
(Results are shown on Leapfrog’s consumer site as “Rate of Episiotomy”)
Specifications: For questions 1 and 2, hospitals should measure and report results as described in the
Maternity Care Outcome Measure Specifications in Section 4 of the Leapfrog Hospital Survey
Reference Book (link found on the ‘Download Survey Materials’ page of the online survey). Answer
questions 1 and 2 based on all cases for the Reporting Time Period per the specifications.
Reporting Time Period: Answer questions #1 – 2 for the 12 months ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
Incidence of Episiotomy in Vaginal Deliveries
1) Total number of vaginal deliveries during the reporting period with Excluded
Populations removed.
______
2) Total number of mothers indicated in question 2 that had an episiotomy
procedure performed.
______
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Maternity Care
2014 Leapfrog Hospital Survey
4D: Process Measures of Quality
(Results are shown on Leapfrog’s consumer site as “Maternity Care Quality”)
Indicate your hospital’s adherence to the following two process measures of quality specific to this
condition, if measured.
Specifications: Hospitals should measure and report results as described in the Maternity Care
Process Measure Specifications in Section 4 of the Leapfrog Hospital Survey Reference Book (link
found on the ‘Download Survey Materials’ page of the online survey)
Reporting Time Period: Answer questions #1 – 2 for 12 months ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
Instructions
For each of the process measures below, indicate in column:
(a) If your hospital has performed a medical record audit on all cases (or a sufficient sample of
them)24 for the Reporting Time Period and measured adherence to the clinical process
guidelines below.
If no, skip columns (b) and (c) in the table below for that guideline.
(b) The number of cases measured against the guideline, either all cases or the sample size, for
this condition i.e., number of cases audited and meeting the criteria for inclusion in the
denominator of the measure.
(c) The number of cases in (b) that adhere to the clinical process guideline for this condition
(numerator).
Guideline
1)
Newborn Bilirubin Screening Prior to
Discharge
If yes, but zero cases met the inclusion
criteria for the denominator, skip 1(b) and
1(c).
2)
Appropriate DVT Prophylaxis in Women
Undergoing Cesarean Delivery
(a)
Measured?
if No,
skip (b) and (c)
Yes
(b)
# Cases
Measured
(denominator)
( c)
# Cases
Adhere
(numerator)
No
_____
_____
______
______
Yes, but zero
cases met the
inclusion
criteria for the
denominator
Yes
No
If yes, but fewer than 10 cases met the
inclusion criteria for the denominator, skip
2(b) and 2(c).
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Version 6.1
Yes, but zero
cases met the
inclusion
criteria for the
denominator
First Release: April 1, 2014
Updated Release: October 23, 2014
Maternity Care
2014 Leapfrog Hospital Survey
Affirmation of Accuracy
As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Maternity Care Section at our hospital,
and I hereby certify that these statements are true, accurate, and reflect the current, normal operating
circumstances at our hospital. I am authorized to make this certification on behalf of our hospital.
The hospital and I understand that The Leapfrog Group, its members and the public are relying on the
truth and accuracy of this information. The hospital and I also understand that The Leapfrog Group will
make this information and/or analyses of this information public through the survey results public
reporting website, The Leapfrog Group’s Hospital Safety Score, and/or other Leapfrog Group products
and services. This information and/or analyses and all intellectual property rights therein shall be the sole
and exclusive property of The Leapfrog Group. The hospital and I acknowledge that The Leapfrog Group
may use this information in a commercial manner for profit. The hospital shall be liable for and shall hold
harmless and indemnify The Leapfrog Group from any and all damages, demands, costs, or causes of
action resulting from any inaccuracies in the information or any misrepresentations in this Affirmation of
Accuracy. The Leapfrog Group and its participants reserve the right to omit or disclaim information that is
not current, accurate or truthful.
Affirmed by _____________________, the hospital’s ___________________________,
(name)
(title)
on _______________________.
(date)
Page 29
Version 6.1
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Updated Release: October 23, 2014
ICU Physician Staffing
2014 Leapfrog Hospital Survey
Section 5: 2014 ICU Physician Staffing (IPS) Standard
(Results shown on Leapfrog’s consumer site as “Specially trained doctors care for ICU patients”)
Link to IPS Fact Sheet: https://leapfroghospitalsurvey.org/web/wp-content/uploads/FSips.pdf
A hospital fulfilling this standard assures that:
All patients in its adult or pediatric general medical and/or surgical ICUs and neuro ICUs are managed or
co-managed25 by physicians certified in critical care medicine26 who:
 Are ordinarily present in the ICU27 (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 exclusively27 in the ICU; and
 At other times . . . ;
– Return more than 95% of ICU calls/pages within 5 minutes, based on a quantified analysis28 of
notification device response time;* and
– Can rely on a physician, physician assistant, nurse practitioner, or a FCCS-certified nurse
“effector”29 who is in the hospital and able to reach ICU patients within 5 minutes in more than
95% of cases, based on a quantified hospital analysis of notification device response time.*
* This may exclude low-urgency calls/pages, if the notification device system can designate low-urgency calls/pages or if the
hospital has an alternative scientific method for documenting high-urgency calls/pages that are not returned within 5 minutes.
If you have no licensed or staffed adult or pediatric general medical and/or surgical ICU beds or neuro
ICUs, this section does not apply to your hospital. Simply answer “No” to the first question to finish the
section. Your hospital’s results will be displayed as ‘Does Not Apply’ on the public website.
Notes:
1. When nationally reported robust measures of ICU performance become available, favorable
performance will replace or supplement the physician staffing standard.
2. Some intensivist “presence” may be accomplished via teleintensivists per Leapfrog’s specifications
(More Information30). However, at this time hospitals cannot fully meet the standard through the sole
use of teleintensivists.
3. On an interim basis, other categories of physicians may be considered by Leapfrog to be “certified in
Critical Care Medicine” (More Information26).
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ICU Physician Staffing
2014 Leapfrog Hospital Survey
1) Does your hospital operate any adult or pediatric general medical and/or
surgical ICUs or neuro ICUs31?
If ‘Yes’, continue; otherwise, skip remaining questions:
2) Are all patients in these ICUs managed or comanaged by one or more physicians who are
certified in critical care medicine?
(More Information32)
Yes
No
Yes, all are certified in critical care
Yes, based on expanded definition of certified
No
3) Is one or more of these physicians ordinarily present in each of these
ICUs during daytime hours for at least 8 hours per day, 7 days per
week, and do they provide clinical care exclusively in one ICU during
these hours? (More Information27)
4) When these physicians are not present in these ICUs on-site or via
telemedicine, do they return more than 95% of calls/pages from these units
within five minutes, based on a quantified analysis28 of notification device
response time?
(This percentage may exclude low-urgency calls/pages, if the notification
device system can designate low-urgency calls/pages or if the hospital has
an alternative scientific method for documenting high-urgency calls/pages
that are not returned within 5 minutes.)
Yes
No
5) When these physicians are not present on-site in the ICU or not able to
reach an ICU patient within 5 minutes, can they rely on a physician,
physician assistant, nurse practitioner, or FCCS-certified nurse “effector29
who is in the hospital and able to reach these ICU patients within five
minutes in more than 95% of the cases, based on a quantified analysis28 of
notification device response time?
(This percentage may exclude low-urgency calls/pages, if the notification
device system can designate low-urgency calls/pages or if the hospital has
an alternative scientific method for documenting high-urgency calls/pages
that are not returned within 5 minutes.)
Yes
No
Yes
No
If you answered "No" to any of questions #2-5 in this section, please answer the following questions for
adult and pediatric, general medical and/or surgical ICUs and neuro ICUs.
6) Are all patients in these ICUs managed or co-managed by one or more
physicians certified in critical care medicine who are:
 ordinarily present on-site in these units;
 for at least 8 hours per day, 4 days per week or 4 hours per day, 7
days per week, and
 providing clinical care exclusively in one ICU during these hours?
(More Information27)
Yes
No
7) Are all patients in these ICUs managed or co-managed by one or more
physicians certified in critical care medicine who are:
 present via telemedicine for 24 hours per day, 7 days per week
 meet modified Leapfrog ICU requirements for intensivist presence in
the ICU via telemedicine (More Information33)
 supported in the establishment and revision of daily care planning for
each ICU patient by an on-site intensivist, hospitalist, anesthesiologist,
or physician trained in emergency medicine
Yes
No
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ICU Physician Staffing
2014 Leapfrog Hospital Survey
8) Are all patients in these ICUs managed or co-managed by one or more
physicians certified in critical care medicine who are:
 on-site at least 4 days per week to establish or revise daily care plans
for each ICU patient?
Yes
No
9) If not all patients are managed or co-managed by physicians certified in
critical care medicine, are some patients managed by these physicians?
Yes
No
10) Does your hospital have a board-approved budget that is adequate to
meet this commitment?
Yes
No
11) Does a clinical pharmacist make daily rounds on patients in these ICUs 7
days per week?
12) Does a physician certified in critical care medicine lead daily multidisciplinary rounds on-site on all patients in these ICUs 7 days per week?
Yes
No
Yes
No
13) When certified physicians are on-site in these ICUs, do they have
responsibility for all ICU admission and discharge decisions?
Yes
No
Affirmation of Accuracy:
As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the ICU Physician Staffing (IPS) Standard
at our hospital, and I hereby certify that these statements are true, accurate, and reflect the current,
normal operating circumstances at our hospital. I am authorized to make this certification on behalf of our
hospital.
The hospital and I understand that The Leapfrog Group, its members and the public are relying on the
truth and accuracy of this information. The hospital and I also understand that The Leapfrog Group will
make this information and/or analyses of this information public through the survey results public
reporting website, The Leapfrog Group’s Hospital Safety Score, and/or other Leapfrog Group products
and services. This information and/or analyses and all intellectual property rights therein shall be the sole
and exclusive property of The Leapfrog Group. The hospital and I acknowledge that The Leapfrog Group
may use this information in a commercial manner for profit. The hospital shall be liable for and shall hold
harmless and indemnify The Leapfrog Group from any and all damages, demands, costs, or causes of
action resulting from any inaccuracies in the information or any misrepresentations in this Affirmation of
Accuracy. The Leapfrog Group and its participants reserve the right to omit or disclaim information that is
not current, accurate or truthful.
Affirmed by _____________________, the hospital’s ___________________________,
(name)
(title)
on _______________________.
(date)
Page 32
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Updated Release: October 23, 2014
Safe Practices Score
2014 Leapfrog Hospital Survey
Section 6: 2014 Leapfrog Safe Practices Score (SPS)
(Results shown on Leapfrog’s consumer site as “Steps to Avoid Harm”)
Link to NQF Safe Practice Fact Sheet: https://leapfroghospitalsurvey.org/web/wpcontent/uploads/FSsafepractices.pdf
In May 2003, the National Quality Forum (NQF) published Safe Practices for Better Healthcare: A
Consensus Report, which listed 30 practices that, if adopted, would have major positive impact on the
safety of patients in healthcare settings. In 2009, NQF modified these Safe Practices and added six new
practices.
This section focuses on eight of the 34 practices in the Safe Practices for Better Healthcare: A
Consensus Report 2010 update.
Before completing this section of the survey, please review some important background information on
the design of this section and how users can most easily complete it. To complete this section, you
should have a full copy of the NQF Safe Practices for Better Healthcare 2010 Update. See link on
‘Download Survey Materials’ page of online survey to download a copy from NQF if you do not
already have one.
Other references available on the ‘Download Survey Materials’ page of the online survey include:
 National Quality Forum Safe Practices for Better Healthcare 2010 Update: Full Report
 Safe Practices Frequently Asked Questions found in Section 6 of the Leapfrog Hospital Survey
Reference Book link found on the ‘Download Survey Materials’ page of the online survey
 Detailed practice-specific FAQ’s found at https://leapfroghospitalsurvey.org/web/wpcontent/uploads/safepracticesFAQ.pdf
For each of the eight NQF-endorsed Safe Practices listed on the next page, please review and check
items, as appropriate. Safe Practice #23 may not apply to your hospital and you can indicate so at the
beginning of that practice. As you complete each practice in the online survey, you can use the navigation
buttons at the bottom of each practice to save and clear responses. Once you have completed
reviewing each Practice, click the “Review of this Practice Complete” checkbox at the top of the
Practice. This will mark the Practice with a green dot in the left-hand navigation of the online
survey tool. After you have finished responding to all eight Safe Practices, you will be able to affirm this
section.
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Safe Practices Score
2014 Leapfrog Hospital Survey
Results Shown On Leapfrog’s
Consumer Site As:
NQF Safe Practice
Weighting
(pts)
1
Culture of Safety Leadership Structures and
Systems
Effective leadership to prevent errors
120
2
Culture Measurement, Feedback, and
Intervention
Staff work together to prevent errors
20
3
Teamwork Training and Skill Building
Training to improve safety
40
4
Risks and Hazards
Track and reduce risks to patients
120
9
Nursing Workforce
Enough qualified nurses
100
17
Medication Reconciliation
Correct medication information is
communicated
35
19
Hand Hygiene
Handwashing
30
23
Prevention of Ventilator Associated
Complications a
Take steps to prevent ventilator
problems
20
485
GRAND TOTAL
a
If this Safe Practice does not apply at your hospital, you can indicate so at the beginning of this Safe-Practice section. To submit
this section of the survey, this Safe Practice needs to be completed, even if only to indicate not applicable to your hospital.
At end of each Safe Practice . . .
Make sure to click “Review of this Practice Complete” checkbox at the top of each Practice even if
no items are checked, to mark the Safe Practice as “Data Entry Complete” (green circle). This checkbox
for all Safe Practices must be checked to submit this section of the survey.
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Safe Practices Score
2014 Leapfrog Hospital Survey
Affirmation of Accuracy
As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the NQF Safe Practices Section at our
hospital, and I hereby certify that these statements are true, accurate, and reflect the current, normal
operating circumstances at our hospital. I am authorized to make this certification on behalf of our
hospital.
The hospital and I understand that The Leapfrog Group, its members and the public are relying on the
truth and accuracy of this information. The hospital and I also understand that The Leapfrog Group will
make this information and/or analyses of this information public through the survey results public
reporting website, The Leapfrog Group’s Hospital Safety Score, and/or other Leapfrog Group products
and services. This information and/or analyses and all intellectual property rights therein shall be the sole
and exclusive property of The Leapfrog Group. The hospital and I acknowledge that The Leapfrog Group
may use this information in a commercial manner for profit. The hospital shall be liable for and shall hold
harmless and indemnify The Leapfrog Group from any and all damages, demands, costs, or causes of
action resulting from any inaccuracies in the information or any misrepresentations in this Affirmation of
Accuracy. The Leapfrog Group and its participants reserve the right to omit or disclaim information that is
not current, accurate or truthful.
Affirmed by _____________________, the hospital’s ___________________________,
(name)
(title)
on _______________________.
(date)
Page 35
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Safe Practices Score
2014 Leapfrog Hospital Survey
Practice #1 – Culture of Safety Leadership Structures and Systems
(page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)
Check all boxes that apply.
1.1
In regard to raising the awareness of key stakeholders to our organization’s efforts to
improve patient safety, the following actions related to identification and mitigation of risk
and hazards have been taken:
a
AWARENESS
b
1.2
c
d
In regard to holding the Board, senior management, mid-level management, physician
leadership, and frontline caregivers directly accountable for results related to mitigating
unsafe practices, the organization has done the following:
a
ACCOUNTABILITY
b
c
d
e
an integrated, patient safety program has been in place for at least the past 12 months
providing oversight and alignment of safe practice activities. (p.76)
a patient safety officer (PSO) has been appointed and communicates regularly with the
Board (governance) and senior administrative leadership; the PSO is the primary point of
contact of the integrated, patient safety program. (p.76)
performance has been documented in performance reviews and/or compensation
incentives for all levels of hospital management and hospital-employed caregivers noted
above. (p.76)
the interdisciplinary patient safety team communicated regularly with management
regarding root cause analyses, progress in meeting safety goals, and providing team
training to caregivers. Actions taken to mitigate system and process failures have been
documented in meeting minutes. (pp.76-77)
the facility reported adverse events to external mandatory or voluntary programs. (p.77)
In regard to implementation of the patient safety program, the Board (governance) and
senior administrative leaders have provided resources to cover the implementation during
the last 12 months, and:
ABILITY
1.3
Board (governance) minutes for the past 12 months reflect regular communication
regarding risks, hazards, culture measurement, and progress towards resolution of safety
and quality problems. (p.75)
patients and family of patients are formal participants in safety and quality committees that
meet on a regularly scheduled basis. (p.75)
steps have been taken to report to the community in the last 12 months of ongoing efforts
to improve safety and quality in the organization and the results of these efforts. (p.75)
all staff and independent practitioners were made aware in the past 12 months of ongoing
efforts to reduce risks and hazards and to improve patient safety and quality in the
organization. (p.75)
Page 36
a
b
patient safety program budgets were sufficiently resourced to support the program,
staffing, and technology investment. (p.77)
documentation of these budgets is available for review by external organizations. (p.77)
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2014 Leapfrog Hospital Survey
1.4
Structures and systems for assuring that leadership is taking direct and specific actions
have been in place for the past 12 months, as evidenced by:
ACTION
a
Page 37
b
c
CEO and senior administrative leaders are personally engaged in reinforcing patient safety
improvements, e.g., “walk-arounds”, holding patient safety meetings, reporting to the Board
(governance). Calendars reflect allocated time. (p.78)
CEO has actively engaged unit, service-line, departmental and mid-level management
leaders in patient safety improvement actions. (p.79)
CEO has established a structure for input into the patient safety program by independent
medical practitioners and medical leadership. Input documented in meeting minutes or
materials. (p.79)
Version 6.1
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Safe Practices Score
2014 Leapfrog Hospital Survey
Practice #2 –Culture Measurement, Feedback, and Intervention
(page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)
Check all boxes that apply.
2.1
In regard to Culture Measurement, our organization has done the following within the last 24
months:
AWARENESS
a
conducted a safety and quality survey using a nationally recognized tool with consideration
of validity, consistency and reliability, with a sample that accounts for 50% of the
aggregated care delivered to patients within the facility, and covers the high patient safety
risk units or departments.(p.88)
If this item ‘a’ is not checked, no other items in this Practice #2 may be checked.
b
2.2
portrayed the results of the culture survey in a report, which reflects both hospital-wide and
individual unit level results. (p.88)
In regard to accountability for improvements in the measurement of the culture of safety,
our organization has done the following within the last 24 months:
ACCOUNTABILITY
a
2.3
b
In regard to the culture of safety measurement, the organization has done the following (or
has had the following in place) within the last 12 months:
ABILITY
a
2.4
involved senior administrative leadership in the identification and selection of sampled
units; and, in the selection of an appropriate tool for measuring the culture of safety. (p.88)
shared the results of the culture measurement survey with the Board (governance) and
senior administrative leadership in a formal report and discussion. (p.88)
b
conducted staff education program(s) on methods to improve the culture of safety, or
conducted team training development programs, based on survey results. Training was
documented in personnel or other administrative records. (p.89)
included the costs of annual culture measurement/follow-up activities in the patient safety
program budget. (p.88)
In regard to culture measurement, feedback, and interventions, our organization has done
the following or has had the following in place within the last 12 months:
ACTION
a
Page 38
b
c
developed or implemented explicit, hospital-wide organizational policies and procedures for
regular culture measurement (p.88)
OR
implemented strategies for improving culture based on survey results. (p.88)
disseminated the results of the survey widely across the institution, with follow-up meetings
held by senior administrative leadership with the sampled units. (p.88)
identified performance improvement interventions based on the survey results, which were
shared with senior administrative leadership and subsequently measured and monitored.
(p.88)
Version 6.1
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Safe Practices Score
2014 Leapfrog Hospital Survey
Practice #3 –Teamwork Training and Skill Building
(page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)
Check all boxes that apply.
3.1
In regard to teamwork training and skill building, our organization has done the following
within the last 12 months:
AWARENESS
a
b
c
d
3.2
In regard to leadership being held accountable for the demonstration of teamwork skills in
the organization, our organization has done the following within the last 12 months:
ACCOUNTABILITY
a
3.3
b
determined, through a literature review or an assessment, a set of targeted units or service
lines for detailed teamwork training and effective teamwork skill building. These units/lines
were identified by the CEO to the Board (governance), senior managers, and medical staff.
(p.97)
provided basic teamwork training34 to the Board (governance), senior managers, medical
staff, mid-level management, and frontline nurses on communication hand-offs and team
failures leading to patient harm. Training was documented in personnel or administrative
records. (p.96)
In regard to effective teamwork training and skill building, our organization has done the
following within the last 12 months:
ABILITY
a
3.4
conducted a literature review of the teamwork training impact in healthcare or in other
settings. (p.101)
OR
conducted a review of available teamwork training programs in progressive organizations.
(p.99)
conducted an assessment of high patient safety risk areas by an Interdisciplinary Patient
Safety Team to determine specific processes in need of teamwork improvement. Those
processes were identified to senior administrative leadership. (p.97)
informed senior management, mid-level management and physician leadership about the
need for teamwork training, skill building, and identified internal resources and possible
resources from progressive organizations. (pp.97-98)
assessed the organizational need for rapid response systems and any associated training.
(p.97)
b
resourced patient safety program budgets in a sufficient manner to support the assessment
of need and team training activities.
provided clinical staff and licensed independent practitioners in the hospital-targeted units
detailed teamwork training and skill building. Participation was documented. (p.96)
Effective team-centered interventions were either in place or were initiated in the past 12
months, as evidenced by:
ACTION
a
Page 39
b
notation in board minutes documenting that the performance improvement targets in
identified units were being addressed. (p.97)
evaluation or documentation of unit or service line results for teams that had received the
detailed team training intervention during the past 12 months. (pp.97-98)
Version 6.1
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2014 Leapfrog Hospital Survey
Practice #4 – Risks and Hazards
(page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)
Check all boxes that apply.
4.1
Within the last 12 months our organization has done the following:
assessed risks and hazards to patients by reviewing retrospective sources, such as:
 serious and sentinel event reporting;
 root cause analyses for adverse events;
 independent comparative mortality and morbidity information with the hospital’s
performance;
 patient safety indicators;
 trigger tools;
 hospital accreditation surveys;
 risk management and filed litigation;
 anonymous internal complaints, including complaints of abusive and disruptive
caregiver behavior; and
 complaints filed with state/federal authorities;
and based on those findings, documented recommendations for improvement. (p.105)
b
assessed risks and hazards to patients using prospective identification tools: Failure
Modes and Effects Analysis (FMEA) and/or Probabilistic Risk Assessment, and has
documented recommendations for improvement. (p.106)
defined their risk mitigation efforts based on their own risk profile, and has documented
recommendations for improvement. (p.107)
integrated results from the three assessments, noted in (a), (b) and (c) above. Results
have been shared widely across the organization, from the Board (governance) to front-line
caregivers. (p.107) This item may not be checked unless all items 4.1a, b, c are checked.
AWARENESS
a
c
d
4.2
Leadership is accountable for identification of risks, hazards and mitigation efforts in the
past year, as evidenced by:
ACCOUNTABILITY
a
4.3
b
approval of an action plan by the CEO and the Board (governance) for undertaking the
assessments of risk, hazards and for the mitigation of risk for patients. (p.106)
incorporation of the identification and mitigation of risks into performance reviews.
OR
outlined financial incentives for leadership and the Patient Safety Officer for identifying and
mitigating risks to patients as identified in the approved action plan.
In regard to developing the ability to appropriately assess risk and hazards, the organization
has done the following or had in place during the last 12 months:
ABILITY
a
Page 40
b
resourced patient safety program budgets sufficiently to support ongoing risk and hazard
assessments and programs for reduction of risk.
provided managers at all levels with training on the tools for monitoring risk in their areas;
senior managers have received training in the integration of risk and hazard information
across the organization. Training was documented. (pp.107-108)
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Safe Practices Score
2014 Leapfrog Hospital Survey
4.4
Structures and systems for assuring that direct and specific actions have taken place to
mitigate risks for the past 12 months, include:
a
ACTION
b
c
Page 41
provided risk identification training to the high risk patient safety units such as: emergency
department, labor and delivery, ICUs, and operating rooms. (p.106)
established or already had in place a structure, developed by the CEO and senior
leadership, for gathering all information related to risks, hazards and mitigation efforts
within the organization with input from all levels of staff within the organization and from
patients and their families. (p.110)
evidence of high-performance or actions taken for the following five patient safety risk
areas: falls, malnutrition, pneumatic tourniquets, aspiration, and workforce fatigue (p.108)
Version 6.1
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Safe Practices Score
2014 Leapfrog Hospital Survey
Practice #9 – Nursing Workforce
(page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)
Is your hospital currently recognized as an American Nurses
Credentialing Center (ANCC) Magnet® organization?35
○ Yes
○ No
If Yes, your hospital will receive full credit for this Safe Practice and no boxes need to be checked. If No,
please check all of the boxes that apply.
9.1
In regard to ensuring adequate and competent nursing staff service and nursing leadership
at all levels, our organization has done the following or has had the following in place within
the last 12 months:
AWARENESS
a
9.2
held at least one educational meeting for clinicians, senior management, mid-level
management, and line management specifically related to the areas of patient safety and
adequate nurse staffing effectiveness. (p.155)
b  performed a risk assessment and an evaluation of the frequency and severity of adverse
events that can be related to nurse staffing. (p.155)
c  submitted a report to the Board (governance) with recommendations for measurable
improvement targets. (p.155)
d  collected and analyzed data of actual unit-specific nurse staffing levels on a quarterly basis
to identify and address potential patient safety-related staffing issues. (p.155)
e  provided unit-specific reports of potential patient safety-related staffing issues to senior
administrative leadership and the Board (governance) at least quarterly. (p.155)
In regard to ensuring adequate and competent nursing staff service and nursing leadership
at all levels, our organization has done the following or has had the following in place within
the last 12 months:
a
ACCOUNTABILITY
b
c
d
e
f
Page 42
held departmental/clinical leadership directly accountable for improvements in performance
through performance reviews or compensation. (p.155)
included senior nursing leadership as part of the hospital senior management team.
(p.155)
reported performance metrics related to this area to the Board (governance). (p.155)
held the Board (governance) and senior administrative leadership accountable for reducing
patient safety risks related to nurse staffing decisions. (p.155)
held the Board (governance) and senior administrative leadership accountable for the
provision of financial resources for nursing services. (p.155)
reported to the Board (governance) the results of the measurable improvement targets.
(p.155)
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Safe Practices Score
2014 Leapfrog Hospital Survey
9.3
In regard to ensuring adequate and competent nursing staff service and nursing leadership
at all levels, our organization has done the following or has had the following in place within
the last 12 months:
a
ABILITY
b
c
d
e
9.4
conducted staff education on maintaining and improving competencies specific to assigned
job duties related to the safety of the patient, with attendance documented. (p.155)
allocated dedicated and compensated staff time to reduce adverse events related to
staffing levels or competency issues.
documented actual expenses incurred during the past year tied to this safe practice.
budgeted financial resources for balancing staffing levels and skill levels to improve
performance. (p.155)
governance has approved a budget for reaching optimal nurse staffing. (p.155)
In regard to ensuring adequate and competent nursing staff service and nursing leadership
at all levels, our organization has done the following within the last 12 months or has had
the following in place during the last 12 months and updates are made regularly:
a
b
ACTION
c
d
e
Page 43
implemented policies and procedures, with input from nurses, to ensure that adequate
nursing staff-to-patient ratios are achieved. (p.154)
developed policies and procedures for effective staffing targets that specify number,
competency and skill mix of nursing staff. (p.155)
implemented a performance improvement project that minimizes the risk to patients from
less than optimal staffing levels. (p.155)
OR
monitored a previously implemented hospital-wide performance improvement program that
measures, and demonstrates full achievement of, the impact of this specific Safe Practice.
(p.155)
provided unit-specific reports of potential patient safety-related staffing issues to senior
administrative leadership and the Board (governance) at least quarterly. (p.155)
provided reports at least annually to the public through the appropriate organizations on
your hospital’s current status in achieving nurse staffing goals. (p.155)
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Safe Practices Score
2014 Leapfrog Hospital Survey
Practice #17 – Medication Reconciliation
(page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)
AWARENESS
Check all boxes that apply.
17.1 In regard to adverse drug events and the medication reconciliation process, our
organization has done the following or has had the following in place within the last 12
months:
completed a review of the literature and identified specific best practices for process
redesign. (pp.225-228)
b  performed a hospital-wide evaluation of the frequency and severity of adverse drug events
associated with medication reconciliation in our patient population.
c  submitted a report to the Board (governance) with recommendations for measurable
improvement targets. (p.224)
In regard to adverse drug events and the medication reconciliation process, our
organization has done the following or has had the following in place within the last 12
months:
a
ACCOUNTABILITY
17.2
a
17.3
b
c
held senior administrative leadership directly accountable for improvements in performance
through performance reviews or compensation.
held the person responsible for patient safety directly accountable for improvements in
performance through performance reviews or compensation.
reported to the Board (governance) the results of the measurable improvement targets.
(p.224)
In regard to adverse drug events and the medication reconciliation process, our
organization has done the following or has had the following in place within the last 12
months:
ABILITY
a
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b
c
conducted staff education and skill development programs, with attendance documented.
(p.221)
conducted an education program for all newly hired clinicians on the importance of
medication reconciliation, with attendance documented. (p.219)
allocated compensated caregiver staff time and dedicated line item budget resources for
best practices development for the organization’s medication reconciliation system. (p.222)
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Safe Practices Score
2014 Leapfrog Hospital Survey
17.4
In regard to adverse drug events and the medication reconciliation process, our
organization has done the following within the last 12 months or has had the following in
place during the last 12 months and updates are made regularly:
a
ACTION
b
c
d
e
f
Page 45
developed explicit, hospital-wide organizational policies and procedures regarding
medication reconciliation.
implemented a hospital-wide performance improvement program that measures the impact
of this specific Safe Practice.
OR
monitored a previously implemented hospital-wide performance improvement program that
measures, and demonstrates full achievement of, the impact of this specific Safe Practice.
implemented standardized processes to obtain and document a complete list of each
patient’s current medications at the beginning of each episode of care. (p.219)
implemented standardized processes to ensure that a complete list of the patient’s
medications is communicated to the next provider of service, including the documentation
of communication between providers. (p.220)
implemented standardized processes to provide the patient, and family/caregiver as
needed, a current list and explanation of the patient’s reconciled medications upon the
patient leaving the organization’s care. (p.220)
have reconciled medications for patients whose care setting, or level of care has changed,
or has had a change in health status. (p.220)
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Safe Practices Score
2014 Leapfrog Hospital Survey
Practice #19 – Hand Hygiene
(page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)
Check all boxes that apply.
19.1 In regard to preventing hospital-acquired infections related to inadequate hand hygiene, our
organization has done the following or has had the following in place within the last 12
months:
AWARENESS
a
19.2
b
In regard to preventing hospital-acquired infections related to inadequate hand hygiene, our
organization has done the following or has had the following in place within the last 12
months:
ACCOUNTABILITY
a
19.3
b
c
d
held clinical leadership directly accountable for this patient safety area through
performance reviews or compensation.
held senior administrative leadership directly accountable for this patient safety area
through performance reviews or compensation.
held the person responsible for patient safety directly accountable for improvements in
performance through performance reviews or compensation.
reported to the Board (governance) the results of the measurable improvement targets.
In regard to preventing hospital-acquired infections related to inadequate hand hygiene, our
organization has done the following or has had the following in place within the last 12
months:
ABILITY
a
19.4
undertaken a hospital-wide educational effort addressing the frequency and severity of
hospital-acquired infections within our patient population and the potential impact of
performance improvement practices related to improvements in hand hygiene. (p.250)
submitted a report to the Board (governance) with recommendations for measurable
improvement targets.
b
conducted staff education/knowledge transfer and skill development programs, with
attendance documented. (p.251)
documented expenditures on staff education related to this Safe Practice in the previous
year.
In regard to preventing hospital-acquired infections related to inadequate hand hygiene, our
organization has done the following within the last 12 months or has had the following in
place during the last 12 months and updates are made regularly:
ACTION
a
Page 46
b
implemented explicit organizational policies and procedures across the entire organization
to prevent hospital-acquired infections due to inadequate hand hygiene including CDC
guidelines with category IA, IB, or IC evidence. (p.250)
implemented a formal performance improvement program addressing hospital-acquired
infections focused on hand hygiene compliance, with regular performance measurement
and tracking improvement (pp.250-251)
OR
monitored a previously implemented hospital-wide performance improvement program that
measures, and demonstrates full achievement of, the impact of this specific Safe Practice.
(pp.250-251)
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Safe Practices Score
2014 Leapfrog Hospital Survey
Practice #23 – Prevention of Ventilator Associated Complications
(page numbers reference NQF Safe Practices for Better Healthcare – 2010 Update report)
Does your facility care for patients on ventilators?
○
○
Yes
No
If Yes, continue with the remainder of this Safe Practice. Otherwise, skip it; the Practice does not apply.
AWARENESS
Check all boxes that apply.
23.1 In regard to complications associated with ventilator use, our organization has done the
following or has had the following in place within the last 12 months:
23.3
conducted an evaluation of the frequency and severity of ventilator-associated
complications in our patient population and communicated findings to senior administrative
and clinical leadership. (p.290)
b
submitted a report to the Board (governance) with recommendations for measurable
improvement targets.
In regard to complications associated with ventilator use, our organization has done the
following or has had the following in place within the last 12 months:
a
ACCOUNTABIL
ITY
23.2
a
b
c
In regard to complications associated with ventilator use, our organization has done the
following or has had the following in place within the last 12 months:
a
ABILITY
held senior administrative leadership and clinical leadership directly accountable for
improvements in performance through performance reviews or compensation.
held the person responsible for patient safety directly accountable for improvements in
performance through performance reviews or compensation.
reported to the Board (governance) the results of the measurable improvement targets.
conducted a staff education/ knowledge transfer and skill development programs on best
practices and strategies to reduce complications with attendance documented.
The organization:
b  documented or can document expenses incurred during the past year tied to this Safe
Practice. (p.293)
c  allocated compensated caregiver staff time to work on this Safe Practice.
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Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Safe Practices Score
2014 Leapfrog Hospital Survey
23.4
In regard to complications associated with ventilator use, our organization has done the
following within the last 12 months or has had the following in place during the last 12
months and updates are made regularly:
a
ACTION
b
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c
d
documented evidence that all ventilated patients are included in an appropriate adult or
pediatric specific bundle or prevention plan that is clearly documented in the medical
record. (p.293)
implemented explicit organizational policies for the disinfection, sterilization, and
maintenance of respiratory equipment that are aligned with evidenced based guidelines.
(p.290)
documented evidence that all ventilated patients and/or their families have been educated
on prevention measures involved in the care of the ventilated patient. (p.292)
implemented a formal performance improvement program with regular performance
measurement and tracking improvement addressing ventilator associated complication
prevention and compliance with prevention strategies. (p.293)
OR
monitored a previously implemented hospital-wide performance improvement program that
measures, and demonstrates full achievement of the impact of this specific Safe Practice.
(p.293)
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Safe Practices Score
2014 Leapfrog Hospital Survey
Questions on Your Hospital’s Culture of Safety Survey
Note: These questions are being asked to inform possible future additions to the survey. A
hospital’s response to these questions will not be used for scoring purposes.
If your hospital indicated ‘yes’ to 2.1.a (conducting a safety and quality survey using a nationally
recognized tool), please answer the questions below related to that survey. Otherwise, please skip these
questions.
1. Which nationally recognized tool did your hospital use for its last survey?
a. Our hospital used AHRQ’s Hospital Survey on Patient Safety Culture (HSOPS)
b. Our hospital used the Safety Attitudes Questionnaire (SAQ)
c. Our hospital used another developed tool
d. Our hospital developed its own survey tool, which may or may not include elements of one of
the national surveys
2. For your last survey, staff in which work areas were surveyed? (check all that apply)
 Emergency Department/Emergency Room
 Operating Rooms (ORs)
 Maternity (OB/GYN)
 Intensive Care Units (ICUs)
 Other
3. For your last survey, which categories of staff were surveyed? (check all that apply)
 Physicians
 Nurses
 Technicians
 Therapists (Occupational or Physical)
 Pharmacists
 Other
4. If you answered ‘c’ or ‘d’ to question #1, please answer the following (4a to 4e):
Were any of the following subset of questions included in your survey tool (check all that apply)?
From the AHRQ HSOPS:
4a. Teamwork Across Hospital Units
F4. There is good cooperation among hospital units that need to work together.
F10. Hospital units work well together to provide the best care for patients.
F2r. Hospital units do not coordinate well with each other (reverse worded).
F6r. It is often unpleasant to work with staff from other hospital units (reverse worded).
 Yes, we included all of the above four questions in our developed survey tool
 No, we did not include all of the above four questions in our developed survey tool
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Updated Release: October 23, 2014
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2014 Leapfrog Hospital Survey
4b. Hospital Handoffs & Transitions
F3r. Things "fall between the cracks" when transferring patients from one unit to another (reverse
worded).
F5r. Important patient care information is often lost during shift changes (reverse worded).
F7r. Problems often occur in the exchange of information across hospital units (reverse worded).
F11r. Shift changes are problematic for patients in this hospital (reverse worded).
 Yes, we included all of the above four questions in our developed survey tool
 No, we did not include all of the above four questions in our developed survey tool
4c. Teamwork Within Hospital Units
A1. People support one another in this unit.
A3. When a lot of work needs to be done quickly, we work together as a team to get the work done.
A4. In this unit, people treat each other with respect.
A11. When one area in this unit gets really busy, others help out.
 Yes, we included all of the above four questions in our developed survey tool
 No, we did not include all of the above four questions in our developed survey tool
From the SAQ:
4d. Teamwork Climate
1. Nurse input is well received in this clinical area.
2. In this clinical area, it is difficult to speak up if I perceive a problem with patient care.
3. Disagreements in this clinical area are resolved appropriately (i.e., not who is right, but what is best for
the patient).
4. I have the support I need from other personnel to care for patients.
5. It is easy for personnel here to ask questions when there is something that they do not understand.
6. The physicians and nurses here work together as a well-coordinated team.
 Yes, we included all of the above six questions in our developed survey tool
 No, we did not include all of the above six questions in our developed survey tool
4e. Safety Climate
7. I would feel safe being treated here as a patient.
8. Medical errors are handled appropriately in this clinical area.
9. I know the proper channels to direct questions regarding patient safety in this clinical area.
10. I receive appropriate feedback about my performance.
11. In this clinical area, it is difficult to discuss errors.
12. I am encouraged by my colleagues to report any patient safety concerns I may have.
13. The culture in this clinical area makes it easy to learn from the errors of others
 Yes, we included all of the above seven questions in our developed survey tool
 No, we did not include all of the above seven questions in our developed survey tool
Page 50
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Managing Serious Errors
2014 Leapfrog Hospital Survey
Section 7: 2014 Managing Serious Errors
Link to Never Events Fact Sheet: https://leapfroghospitalsurvey.org/web/wpcontent/uploads/neverevents.pdf
This section of the survey addresses the occurrence of serious errors in hospitals.
Hospitals are asked to implement the five principles of Leapfrog’s Never Events policy when a serious
error or “never event” occurs within their facility. More information on the five principles of the policy and a
complete list of included “never events” can be found at:
http://www.leapfroggroup.org/for_hospitals/leapfrog_hospital_survey_copy/never_events/
In addition to the management of serious errors, hospitals are asked to report their rates of two hospitalacquired infections– central line associated bloodstream infections and catheter-associated urinary tract
infections - and two hospital-acquired conditions – stage III or IV pressure ulcers and injuries.
Each hospital fully meeting the standards for this section of the survey:
1. Has agreed to implement the five principles of Leapfrog’s Never Events policy if a never event occurs
within their facility.
2. Has a standardized infection ratio of zero for patients in the ICU, as measured by dividing the number
of observed CLABSI events by the “expected” number of events.
3. Has a standardized infection ratio of less than 0.293 for patients in the ICU, as measured by dividing
the number of observed UTI events by the “expected” number of events.
4. Has a rate of 0.000 per 1,000 patient discharges for hospital-acquired stage III or IV pressure ulcers.
5. Has a rate less than or equal to 0.16 per 1,000 patient discharges for hospital-acquired injuries.
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Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Managing Serious Errors
2014 Leapfrog Hospital Survey
7A: The Leapfrog Group Serious Reportable Events “Never Events”
Policy Statement
(Results shown on Leapfrog’s consumer site as “Managing Serious Errors”)
The Leapfrog Group asks hospitals to agree to all of the following principles if a never event36 occurs
within their facility:
 We will apologize to the patient37 and/or family affected by the never event
 We will report the event to at least one of the following external agencies38 within 10 days of
becoming aware that the never event has occurred:
 Joint Commission, as part of its Sentinel Events policy
 State reporting program for medical errors
 Patient Safety Organization (as defined in The Patient Safety and Quality Improvement Act of
2005)
 We agree to perform a root cause analysis39, consistent with instructions from the chosen
reporting agency
 We will waive all costs directly related to a serious reportable adverse event
 We will make a copy of this policy available to patients, patients’ family members, and payers
upon request
Important Note: To earn credit for this question, hospitals must have a policy in place that addresses the
National Quality Forum’s list of Serious Report Events. All references to “never event” or “serious
reportable event” are specific to the National Quality Forum list available at
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=69573.
Indicate below your hospital’s efforts in relation to the Leapfrog Group policy statement on “Never
Events.”
1) Has your hospital implemented a policy that adheres to all of the principles
of the Leapfrog Group Policy Statement, above?
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Yes
No
First Release: April 1, 2014
Updated Release: October 23, 2014
Managing Serious Errors
2014 Leapfrog Hospital Survey
7B: Hospital-Acquired Conditions – CLABSI
(Results shown on Leapfrog’s consumer site as “Reduce Central-line Infections in ICUs”)
Specifications: See CLABSI Specifications in Section 7 of the Leapfrog Hospital Survey Reference Book
(link found on the online survey ‘Download Survey Materials’ page) for counting central line bloodstream
infections, central line days, and for appropriate inclusion and exclusion criteria.
Reporting Time Period: Answer questions #1-19 for the 12-months ending :
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
1) Does your hospital care for patients with central lines in an intensive care unit
(ICU)40? If no, skip questions 2 –19; otherwise continue.
Yes
No
2) Has your hospital measured its incidence of Central Line Associated Blood
Stream Infections (CLABSI) for the Reporting Time Period and chosen to report
this information to the survey?
If no, score will show as ‘Declined to Respond’ and skip questions 3 –19;
otherwise continue.
3) Does your hospital utilize personnel trained in human factors engineering41 in
conducting root-cause analyses of adverse events (e.g., central line associated
bloodstream infections)?
Continue with question 4 regardless.
Yes
No
4) Is your hospital designated as a “major teaching hospital”?
(Definition of Major Teaching Hospital42)
Continue with questions 5-19 regardless.
Yes
No
Yes
No
Instructions
For each ICU below, responses should be the same data reported and accepted by the CDC/NHSN
(recognizing that the reporting time period may be slightly different than what is stated below). If data are not
submitted to the CDC/NHSN, hospitals should indicate “not measured” in Q2, and skip the remainder of the
questions in this subsection.
For each of the fifteen ICUs listed below, indicate in column:
(a) if your hospital operates this type of ICU
If no, skip columns (b) and (c) in the table below for that ICU type.
(b) Total central line days during the reporting period in the specified ICU (denominator) reported to the
CDC/National Healthcare Safety Network (NHSN); see CLABSI Specifications in Section 7 of the Leapfrog
Hospital Survey Reference Book for more information.
(c) Total number of central line associated bloodstream infections during the reporting period in the specified
ICU reported to the CDC/NHSN (numerator); see CLABSI Specifications in Section 7 of the Leapfrog
Hospital Survey Reference Book for more information.
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Updated Release: October 23, 2014
Managing Serious Errors
2014 Leapfrog Hospital Survey
Questions 5-19 required, if “yes” to Q1 and Q2 above.
ICU Type
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
Medical
(a)
Does your hospital
operate this type of ICU?
if No, skip (b) & (c)
Yes
No
(b)
# of Central
Line Days
(c)
# of Central Line Associated
Bloodstream Infections
______
______
Yes
No
______
______
Yes
No
______
______
Yes
No
______
______
Yes
No
______
______
Pediatric
Medical/Surgical
Yes
No
______
______
Pediatric
Cardiothoracic
Yes
No
______
______
Coronary Care
Yes
No
______
______
Surgical
Cardiothoracic
Yes
No
______
______
Neurology
Yes
No
______
______
Yes
No
______
______
Yes
No
______
______
Yes
No
______
______
Surgical
Medical/Surgical
Pediatric Medical
Pediatric Surgical
Neurosurgical
Burn
Trauma
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Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Managing Serious Errors
2014 Leapfrog Hospital Survey
ICU Type
18)
Level II/III NICU
(a)
Does your hospital
operate this type of ICU?
if No, skip (b) & (c)
Yes
No
(b)
# of Central
Line Days
(c)
# of Central Line Associated
Bloodstream Infections
Birth weight Category
i)
<= 750 g
______
______
ii)
751 – 1, 000 g
______
______
iii)
1,001 – 1,500 g
______
______
iv)
1,501 – 2,500 g
______
______
v)
> 2,500 g
______
______
ICU Type
19)
Level III NICU
(a)
Does your hospital
operate this type of ICU?
if No, skip (b) & (c)
Yes
No
(b)
# of Central
Line Days
(c)
# of Central Line Associated
Bloodstream Infections
Birth weight Category
i)
<= 750 g
______
______
ii)
751 – 1, 000 g
______
______
iii)
1,001 – 1,500 g
______
______
iv)
1,501 – 2,500 g
______
______
v)
> 2,500 g
______
______
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Updated Release: October 23, 2014
Managing Serious Errors
2014 Leapfrog Hospital Survey
7C: Hospital-Acquired Conditions – CAUTI
(Results shown on Leapfrog’s consumer site as “Reduce Urinary Tract Infections in ICUs”)
Specifications: See CAUTI Specifications in Section 7 of the Leapfrog Hospital Survey Reference Book
(link found on the online survey ‘Download Survey Materials’ page) for counting catheter associated urinary
tract infections, catheter days, and for appropriate inclusion and exclusion criteria.
Reporting Time Period: Answer questions #1-15 for the 12-months ending :
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
1) Does your hospital care for patients with indwelling urinary catheters in an
intensive care unit (ICU)43? If no, skip questions 2-15; otherwise continue.
Yes
No
2) Has your hospital measured its incidence of Catheter-associated Urinary Tract
Infections (CAUTI) for the Reporting Time Period and chosen to report this
information to the survey?
If no, score will show as ‘Declined to Respond’ and skip questions 3-15;
otherwise continue.
Yes
No
3) Is your hospital designated as a “major teaching hospital”?
(Definition of Major Teaching Hospital44)
Continue with questions 4-15 regardless.
Yes
No
Instructions
For each ICU below, responses should be the same data reported and accepted by the CDC/NHSN
(recognizing that the reporting time period may be slightly different than what is stated below). If data are not
submitted to the CDC/NHSN, hospitals should indicate “not measured” on Q2, and skip the remainder of the
questions in this subsection.
For each of the fifteen ICUs listed below, indicate in column:
(a) If your hospital operates this type of ICU. If no, skip columns (b) and (c) in the table below for that
ICU type.
(b) Total urinary catheter days during the reporting period in the specified ICU as reported to the
CDC/NHSN (denominator); see CAUTI Specifications in Section 7 of the Leapfrog Hospital
Survey Reference Book for more information.
(c) Total number of catheter-associated urinary tract infections during the reporting period in the
specified ICU as reported to the CDC/NHSN (numerator); see CAUTI Specifications in Section 7
of the Leapfrog Hospital Survey Reference Book for more information.
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Managing Serious Errors
2014 Leapfrog Hospital Survey
Questions 4-15 required, if “yes” to Q1 and Q2 above.
(b)
# of Urinary
Catheter Days
(c)
# of Catheter-associated
Urinary Tract Infections
(per CDC’s Criterion)
______
______
Yes
No
______
______
Yes
No
______
______
Yes
No
______
______
Pediatric
Medical/Surgical
Yes
No
______
______
Pediatric
Cardiothoracic
Yes
No
______
______
Medical Cardiac
Yes
No
______
______
Surgical
Cardiothoracic
Yes
No
______
______
Neurology
Yes
No
______
______
Yes
No
______
______
Yes
No
______
______
Yes
No
______
______
ICU Type
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
Medical
Surgical
Medical/Surgical
Pediatric Medical
Neurosurgical
Burn
Trauma
Page 57
(a)
Does your hospital
operate this type of ICU?
if No, skip (b) & (c)
Yes
No
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Managing Serious Errors
2014 Leapfrog Hospital Survey
7D: Hospital-Acquired Conditions – Pressure Ulcer and Injuries
(Results shown on Leapfrog’s consumer site as “Reduce Hospital-Acquired Pressure Ulcers”
and “Reduce Hospital-Acquired Injuries”)
Pediatric hospitals skip questions #1-4.
Critical access hospitals (CAH) can voluntarily report on questions #1-4, otherwise answer No to
question #1.
Specifications: Hospitals should refer to Pressure Ulcers and Injuries Specifications in Section 7 of
the Leapfrog Hospital Survey Reference Book (link found on the ‘Download Survey Materials’ page of
the online survey) for counting patient discharges and events.
Reporting Time Period: Answer questions #1-4 for the 12-months ending:
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
1) Has your hospital collected Present-on-Admission (POA) indicators for the
Reporting Time Period, tabulated HAC measures as specified here for that
time period, and chosen to report this information to the survey?
If no, score will show as ‘Declined to Respond’ and skip remaining questions
#2-4. If hospital is a critical access hospital, and selects “no,” score will show
as “Does Not Apply”.
2) Total number of adult inpatient discharges (including deaths) during the
reporting period.
Yes
No
________
Hospital-Acquired Pressure Ulcers
3) Number of discharges in question #2 with a hospital-acquired stage III or IV
Pressure Ulcer.
________
Hospital-Acquired Injuries
4) Number of discharges in question #2 with a hospital-acquired injury.
________
Page 58
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Managing Serious Errors
2014 Leapfrog Hospital Survey
Affirmation of Accuracy:
As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Managing Serious Errors Section at our
hospital, and I hereby certify that these statements are true, accurate, and reflect the current, normal
operating circumstances at our hospital. I am authorized to make this certification on behalf of our
hospital.
The hospital and I understand that The Leapfrog Group, its members and the public are relying on the
truth and accuracy of this information. The hospital and I also understand that The Leapfrog Group will
make this information and/or analyses of this information public through the survey results public
reporting website, The Leapfrog Group’s Hospital Safety Score, and/or other Leapfrog Group products
and services. This information and/or analyses and all intellectual property rights therein shall be the sole
and exclusive property of The Leapfrog Group. The hospital and I acknowledge that The Leapfrog Group
may use this information in a commercial manner for profit. The hospital shall be liable for and shall hold
harmless and indemnify The Leapfrog Group from any and all damages, demands, costs, or causes of
action resulting from any inaccuracies in the information or any misrepresentations in this Affirmation of
Accuracy. The Leapfrog Group and its participants reserve the right to omit or disclaim information that is
not current, accurate or truthful.
Affirmed by _____________________, the hospital’s ___________________________,
(name)
(title)
on _______________________.
(date)
Page 59
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Safety-Focused Scheduling
2014 Leapfrog Hospital Survey
Section 8: 2014 Safety-Focused Scheduling
Link to Safety-Focused Scheduling Fact Sheet: https://leapfroghospitalsurvey.org/web/wpcontent/uploads/FSscheduling.pdf
This section of the survey asks hospitals about their success in using management methods to smooth
patient flow across operating rooms, eliminating unnatural fluctuations in patient scheduling and resulting
in more optimal scheduling of patient procedures. With the widespread use of these management
methods, the need for building additional capacities will either be postponed or eliminated.
Each hospital fully meeting the standard for Safety-Focused Scheduling:
1. Has reported an average utilization of 85% or greater across those operating rooms that service
inpatients
2. In addition, Leapfrog will calculate the percentage of surgical subspecialties that achieve their
own internal access targets for unscheduled cases, stratified by urgency level. However, these
results will only be posted on the hospital’s Details page. The results will not be publicly
reported at www.leapfroggroup.org/cp until the 2015 survey cycle.
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Safety-Focused Scheduling
2014 Leapfrog Hospital Survey
Glossary of Terms
Operating room that services inpatients: An operating room that is used for inpatient surgery, either
exclusively, or in combination with outpatient surgery.
Elective/scheduled surgery: A surgery that is scheduled in advance because it does not involve a
medical emergency.
Urgent surgery: A surgery that can wait until the patient is medically stable, but should generally be done
today or tomorrow.
Emergent surgery: A surgery that must be performed without delay; the patient has no choice other than
immediate surgery, if they do not want to risk permanent disability or death.
Prime time hours: The normal hours an operating room is opened and staffed. For a typical hospital,
‘prime time’ will start around 7 am and go until 3-5 pm.
Available ‘prime time’ hours: The total hours in a month an operating room is opened and staffed
during ‘prime time’ hours.
Utilized prime time hours: The total hours in a month an operating room is being used for surgery or
being turned over, during ‘prime time’ hours. The time an operating room is sitting idle is NOT included in
the utilized prime time hours, including time between cases.
Turnover time: The difference in time between ‘wheels out’ of the last patient to the room being ready for
the next surgery (not necessarily when the next patient was wheeled in). Hospitals may need to commit
manual resources to accurately collect these data (see sampling instructions in the Survey Reference
Book).
Urgency level: A category assigned by the hospital itself to reflect the urgency of an unscheduled
surgical case.
Access target: The time goal set by the hospital itself reflecting how quickly a case with a specific
urgency level should be accommodated in an operating room.
Page 61
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Updated Release: October 23, 2014
Safety-Focused Scheduling
2014 Leapfrog Hospital Survey
8A: Safety-Focused Scheduling – Utilization
(Results will be shown on Leapfrog’s consumer site as “Safety-Focused Scheduling”)
Questions #1-2 are designed to see if this section of the survey applies to your hospital.
1) Does your hospital operate more than one operating room that services
inpatients (i.e., exclude any operating rooms that exclusively service
outpatients)?
Yes
No
If ‘Yes’, please continue with question #2; If “No”, please affirm section
responses and skip to the next survey section.
2) Did elective inpatient surgeries make up 10% or more of your hospital’s
total inpatient admissions during the latest 12-month period?
If ‘Yes,’ please continue with question #3.
Yes
If ‘No,’
 If your hospital chooses to not report on the remaining questions, your
hospital will be scored as “Response Not Required”. Please affirm
section responses and skip to the next survey section.
 If your hospital chooses to report on the remaining questions, progress
toward meeting the standard will be assessed using the same criteria
as other hospitals. Please continue with question #3.
3) For those operating rooms that service inpatients, has your hospital
designated specific operating rooms for “elective/scheduled” surgeries and
other operating rooms for “urgent/emergent” surgeries?
If ‘Yes,’ answer questions #4 and 5
If ‘No,’ answer questions #6 and 7
If ‘Did not measure,’ skip the remainder of the section.
No, will skip remainder
of the questions
No, will complete
remainder of the
questions
Yes
No
Did not measure
Hospitals that did not measure utilization of operating rooms that service
inpatients will be reported as Declined to Respond.
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Safety-Focused Scheduling
2014 Leapfrog Hospital Survey
The next set of questions asks hospitals about the available and utilized ‘prime time’ hours of
your hospital’s operating rooms that service inpatients.
Reporting Time Periods: The most recent 6 or 12 consecutive months of data that is available at the
time of survey submission.
Specifications: All hospitals should use the Safety-Focused Scheduling Specifications in Section 8 of
the Leapfrog Hospital Survey Reference Book (link found on the online survey ‘Download Survey
Materials’ page) to identify operating rooms that should be included in this section and to find definitions
of available and utilized ‘prime time’ hours.
Hospitals that have operating rooms designated specifically for “scheduled/elective” inpatient surgeries
and that have other operating rooms designated specifically for “urgent/emergent” surgeries should
answer Q4 and Q5 based on the status of operating rooms designated for “scheduled/elective” surgeries
only.
If ‘Yes’ to question #3 above, answer questions #4 and 5.
4) In those operating rooms that service inpatients and that have been
designated for scheduled and/or elective surgeries, what were your
hospital’s total available ‘prime time’ hours during the reporting period?
(Responses should be rounded to the nearest whole number. Do not enter
ranges of time or text).
5) In those operating rooms that service inpatients and that have been
designated for scheduled and/or elective surgeries, what were your
hospital’s total utilized ‘prime time’ hours during the reporting period?
(Responses should be rounded to the nearest whole number. Do not enter
ranges of time or text).
_______
_______
Hospitals that do NOT have operating rooms designated specifically for “scheduled/elective” inpatient
surgeries and that do NOT have other operating rooms designated specifically for “urgent/emergent”
surgeries should answer Q6 and Q7 based on the status of all operating rooms that service inpatients.
If ‘No’ to question #3 above, answer questions #6 and 7.
6) Across all operating rooms that service inpatients, what were your hospital’s
total available ‘prime time’ hours during the reporting period?
(Responses should be rounded to the nearest whole number. Do not enter
ranges of time or text).
7) Across all operating rooms that service inpatients, what were your hospital’s
total utilized ‘prime time’ hours during the reporting period?
(Responses should be rounded to the nearest whole number. Do not enter
ranges of time or text).
Page 63
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_______
_______
First Release: April 1, 2014
Updated Release: October 23, 2014
Safety-Focused Scheduling
2014 Leapfrog Hospital Survey
8B: Safety-Focused Scheduling - Patient Access to Operating Rooms
(Results will not be shown on Leapfrog’s consumer site. Results will be available to hospitals
ONLY on their Details page – link in survey dashboard - after July 25, 2014)
Reporting Time Periods: The same 6 or 12 consecutive months of data that were used to respond to the
OR Utilization subsection above.
1) Has your hospital set targets for access to operating rooms for unscheduled
cases, delineated by surgical subspecialty and urgency level?
Yes
No
If ‘Yes,’ please continue with question #2.
If ‘No,’ please complete the Affirmation of Accuracy.
2) Is your hospital able to measure and report on the percentage of
unscheduled cases that met the access targets during the reporting time
period?
Yes
Choose Not to Report
If ‘Yes,’ please continue with question #3.
If ‘Choose Not to Report’ or ‘Can Not Measure’, please complete the Affirmation
of Accuracy.
Can Not Measure
3) For each surgical subspecialty that your hospital regularly provides, please indicate:
 In column (A), the name of the surgical subspecialty.
 In column (B), your hospital’s own defined urgency levels for unscheduled cases for this
surgical subspecialty.
 In column (C), the internal target (in hours) for cases of that surgical subspecialty and
urgency level to have access to an operating room.
 In column (D), the percentage of cases that met that internal target during the reporting
period.
(A) Name of Surgical
Subspecialty
(Limit to 10
subspecialties)
e.g., Cardiac surgery
e.g., Cardiac surgery
e.g., Orthopedic surgery
Page 64
(B) Urgency Level
for
Unscheduled
Cases
Urgent
Emergent
Urgent
Version 6.1
(C) Internal
Access Target
for Cases of
that Urgency
Level (hours)
0.5 hours
2.0 hours
1.0 hour
(D) % of Cases
During the
Reporting Period
That Met Access
Target
80%
72%
62%
First Release: April 1, 2014
Updated Release: October 23, 2014
Safety-Focused Scheduling
2014 Leapfrog Hospital Survey
Affirmation of Accuracy:
As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Safety-focused Scheduling Section at
our hospital, and I hereby certify that these statements are true, accurate, and reflect the current, normal
operating circumstances at our hospital. I am authorized to make this certification on behalf of our
hospital.
The hospital and I understand that The Leapfrog Group, its members and the public are relying on the
truth and accuracy of this information. The hospital and I also understand that The Leapfrog Group will
make this information and/or analyses of this information public through the survey results public
reporting website, The Leapfrog Group’s Hospital Safety Score, and/or other Leapfrog Group products
and services. This information and/or analyses and all intellectual property rights therein shall be the sole
and exclusive property of The Leapfrog Group. The hospital and I acknowledge that The Leapfrog Group
may use this information in a commercial manner for profit. The hospital shall be liable for and shall hold
harmless and indemnify The Leapfrog Group from any and all damages, demands, costs, or causes of
action resulting from any inaccuracies in the information or any misrepresentations in this Affirmation of
Accuracy. The Leapfrog Group and its participants reserve the right to omit or disclaim information that is
not current, accurate or truthful.
Affirmed by _____________________, the hospital’s ___________________________,
(name)
(title)
on _______________________.
Page 65
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Resource Use for Common Acute
Conditions
2014 Leapfrog Hospital Survey
Section 9: 2014 Resource Use for Common Acute Conditions
Note: This section does not apply to Pediatric Hospitals. Critical Access Hospitals can report on
this section. Critical Access Hospitals that do not voluntarily report to the CMS should respond
“No” to question 1, and then skip the remainder of the section. The hospital will be shown as
“Does Not Apply.”
This section of the survey addresses how judiciously hospitals use resources to provide care for their
patients. The section focuses on hospital resource use (readmission and length of stay) for three common
acute conditions: heart attack, heart failure, and pneumonia.
In Section 9, Leapfrog asks hospitals to report their 30-day readmission rates for Medicare patients that
are collected and calculated by CMS for three common acute conditions: heart attack (acute myocardial
infarction), heart failure, and pneumonia. Leapfrog will calculate a composite readmission score using the
readmission rates for those conditions where more than 25 cases were reported. The number of cases
reported for each condition will be used as the weights in the composite score.
Also in this section, Leapfrog asks hospitals to report on their actual (geometric) mean length of stay for
the same three common acute conditions and those will be compared to a hospital’s expected mean
length of stay for the same conditions. A composite length of stay score will be calculated using the riskadjusted length of stays for each condition. The number of cases reported for each condition will be used
as weights in the composite score.
Each hospital fully meeting the standards for the Resource Use section:
1. Is in the best (lowest) performance category for overall Readmission composite
2. Is in the best (lowest) performance category for overall Length of Stay (LOS) composite
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Resource Use for Common Acute
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2014 Leapfrog Hospital Survey
Resource Use for Common Acute Conditions
1) Does your hospital participate in the CMS Hospital Inpatient Quality Reporting
Program or voluntarily participate in the CMS Readmissions Program?
Yes
No
If no, skip remaining questions in Section 9; the hospital will be shown as “Does
Not Apply” for both Length of Stay and Readmissions.
Otherwise continue with question #2.
2) Does your hospital share a Medicare Provider Number (MPN) with another
facility, and therefore the data submitted and reported by CMS represents
combined results for more than one facility?
Yes
No
Continue on to Section 9A, Q1 regardless.
Note: Due to the clinical specificity needed, specifications for determining case count for the length of stay
measures may DIFFER from those used by the hospital to determine eligible cases when measuring
readmission for CMS.
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Updated Release: October 23, 2014
Resource Use for Common Acute
Conditions
2014 Leapfrog Hospital Survey
9A: Acute Myocardial Infarction
Risk-adjusted Length of Stay and 30-day Risk-adjusted Readmission Rate
(Results show on Leapfrog’s consumer site separately as “Readmissions for Common Acute
Conditions” and “Length of Stay for Common Acute Conditions”
Acute Myocardial Infarction (AMI) – Risk-adjusted Length of Stay
Specifications: See Length of Stay Measures Specifications in Section 9 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey),
including the list of ICD-9 codes that should be used to answer question #2.
Reporting Time Period: Answer questions #1-4 for the 12-months (if >=25 cases during a 12-month
period) or 24-months (if < 25 cases in a 12-month period) ending :
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
* Report for the same 12- or 24-month period, consistent with responses to questions #1-4
1) Does your hospital treat patients for acute myocardial infarction? (If your
hospital only treats AMI patients that are too unstable for safe transfer,
answer “no.”)
Yes
No
If no, skip the remaining questions in the AMI section, and continue on to the
Heart Failure section.
If yes, continue to question #2.
2) Total number of inpatient discharges (including deaths) at this hospital
location with a principal diagnosis of AMI
Number of patients for the reporting time period.
______
If response is less than 25, skip the remaining questions in the AMI section
(both length of stay and readmission questions) and continue on to Heart
Failure section. Hospital will be shown as “Unable to Calculate Score” for
both AMI LOS and AMI Readmission Rate.
If response is 25 or more, continue to question #3
.
3) Geometric mean length of stay for discharges reported in question 1.
See ‘Download Survey Materials’ link on home page for calculation
worksheet. Report value to two decimal place precision
Page 68
Version 6.1
_______
(e.g., 7.65)
First Release: April 1, 2014
Updated Release: October 23, 2014
Resource Use for Common Acute
Conditions
2014 Leapfrog Hospital Survey
4) Number of discharges reported in question 2 which had the selected risk factor present, respectively:
(enter 0 if no discharges had that risk factor present)
a)
Risk Factor
Description, brief – see detailed specifications
RF17
CABG
Number of
Discharges
in Question #2 with
Risk Factor Present
_______
b)
RF33
Congestive heart failure
_______
c)
RF085
Pneumonia
_______
d)
RF070
Cardio-respiratory failure and shock
_______
e)
RF050
Age >=65
_______
f)
RF32
Stroke or transient ischemic attack
_______
Acute Myocardial Infarction (AMI) – 30-day Risk-adjusted Readmission Rate
Specifications: See Readmission Measures Specifications in Section 9 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
Reporting Time Period: Answer questions # 5-6 based on the most recent CMS 36-month report
published at www.HospitalCompare.hhs.gov.
Note: CMS updates the readmission rates for Heart Attack, Heart Failure, and Pneumonia annually in
July using a rolling 36-month reporting period. Hospitals that submit a survey prior to the CMS update in
July, are encouraged to come back into their survey to update the responses to this section.
5) Number of AMI cases reported by CMS (in most recent 36-month report)
If the number of cases reported by CMS is less than 25, skip Q6.
______
6) 30-day Risk Standardized Readmission Rate for AMI reported by CMS (in
most recent 36-month report)
Enter to one decimal place precision. Do not round.
______
(i.e. 23.5)
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Resource Use for Common Acute
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2014 Leapfrog Hospital Survey
9B: Heart Failure
Risk-adjusted Length of Stay and 30-day Risk-adjusted Readmission Rate
(Results show on Leapfrog’s consumer site separately as “Readmissions for Common Acute
Conditions” and “Length of Stay for Common Acute Conditions”
Heart Failure – Risk-adjusted Length of Stay
Specifications: See Length of Stay Measures Specifications in Section 9 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey),
including the list of ICD-9 codes that should be used to answer question #2.
Reporting Time Period: Answer questions #1-4 for the 12-months (if >=25 cases during a 12-month
period) or 24-months (if <25 cases during 12-month period) ending :
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
* Report for the same 12- or 24-month period, consistent with responses to questions #1-4
1) Does your hospital treat patients for heart failure? (If your hospital only treats
heart failure patients that are too unstable for safe transfer, answer “no.”)
Yes
No
If no, skip the remaining questions in the Heart Failure section, and continue
on to the Pneumonia section. .
If yes, continue to question #2.
2) Total number of inpatient discharges (including deaths) at this hospital
location with a principal diagnosis of heart failure
Number of patients for the reporting time period.
______
If response is less than 25, skip the remaining questions in the Heart Failure
section (both length of stay and readmission questions) and continue to the
Pneumonia section. . Hospital will be shown as “Unable to Calculate Score”
for both Heart Failure LOS and Heart Failure Readmission Rate.
If response is 25 or more, continue to question #3.
3) Geometric mean length of stay for discharges reported in question 2.
See ‘Download Survey Materials’ link on home page for calculation
worksheet. Report value to two decimal place precision
Page 70
Version 6.1
_______
(e.g., 7.65)
First Release: April 1, 2014
Updated Release: October 23, 2014
Resource Use for Common Acute
Conditions
2014 Leapfrog Hospital Survey
4) Number of patients reported in question 2 which had the selected risk factor present, respectively:
(enter 0 if no patients had that risk factor present)
Number of Patients
Risk Factor Description, brief – see detailed specifications
in Question #2 with
Risk Factor Present
a)
RF083
Renal failure
______
b)
RF070
Cardio-respiratory failure and shock
______
c)
RF119
Septicemia/shock
______
d)
RF122
Urinary tract infection
_______
e)
RF085
Pneumonia
_______
f)
RF108
Disorders of fluid/electrolyte/acid-base
_______
g)
RF120
Pleural effusion/pneumothorax
_______
Heart Failure – 30-day Risk-adjusted Readmission Rate
Specifications: See Readmission Measures Specifications in Section 9 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
Reporting Time Period: Answer questions #5-6 based on the most recent CMS 36-month report
published at www.HospitalCompare.hhs.gov.
Note: CMS updates the readmission rates for Heart Attack, Heart Failure, and Pneumonia annually in
July using a rolling 36-month reporting period. Hospitals that submit a survey prior to the CMS update in
July, are encouraged to come back into their survey to update the responses to this section.
5) Number of Heart Failure cases reported by CMS (in most recent 36-month
report)
If the number of cases reported by CMS is less than 25, skip Q6.
6) 30-day Risk Standardized Readmission Rate reported by CMS (in most
recent 36-month report)
Enter to one decimal place precision. Do not round.
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______
______
(i.e. 23.5)
First Release: April 1, 2014
Updated Release: October 23, 2014
Resource Use for Common Acute
Conditions
2014 Leapfrog Hospital Survey
9C: Pneumonia
Risk-adjusted Length of Stay and 30-day Risk-adjusted Readmission Rate
(Results show on Leapfrog’s consumer site separately as “Readmissions for Common Acute
Conditions” and “Length of Stay for Common Acute Conditions”
Pneumonia – Risk-adjusted Length of Stay
Specifications: See Length of Stay Measures Specifications in Section 9 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey),
including the list of ICD-9 codes that should be used to answer question 2.
Reporting Time Period: Answer questions #1-4 for the 12-months (if >=25 cases during a 12-month
period) or 24-months (if <25 during a 12-month period) ending :
 December 31, 2013, for surveys submitted prior to September 1, 2014;
 June 30, 2014, for surveys (re)submitted on or after September 1, 2014.
* Report for the same 12- or 24-month period, consistent with responses to questions #1-4
1) Does your hospital treat patients for pneumonia?
(If your hospital only treats pneumonia patients that are too unstable for safe
transfer, answer “no.”)
Yes
No
If no, skip the remaining questions in this section and affirm your hospital’s
responses to this section.
If yes, continue to question #2.
2) Total number of inpatient discharges (including deaths) at this hospital
location with a principal diagnosis of pneumonia
Number of patients for the reporting time period.
______
If response is less than 25, skip the remaining questions in this section and
affirm your hospital’s responses to this section. Hospital will be shown as
“Unable to Calculate Score” for both Pneumonia LOS and Pneumonia
Readmission Rate.
If response is 25 or more, continue to question #3.
3) Geometric mean length of stay for discharges reported in question 2.
See ‘Download Survey Materials’ link on home page for calculation
worksheet. Report value to two decimal place precision
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_______
(e.g., 7.65)
First Release: April 1, 2014
Updated Release: October 23, 2014
Resource Use for Common Acute
Conditions
2014 Leapfrog Hospital Survey
4) Number of patients reported in question 2 which had the selected risk factor present, respectively:
(enter 0 if no patients had that risk factor present)
Number of
Risk Factor Description, brief – see detailed specifications
Discharges
in Question #2 with
Risk Factor Present
a) RF45
Respiratory failure
_______
b)
RF33
Congestive heart failure
_______
c)
RF087
Protein-calorie malnutrition
_______
d)
RF112
History of infection
_______
e)
RF43
Pleural effusion
_______
f)
Age >=65
RF050
g)
RF44
_______
Septicemia
_______
Pneumonia – 30-day Risk-adjusted Readmission Rate
Specifications: See Readmission Measures Specifications in Section 9 of the Leapfrog Hospital
Survey Reference Book (link found on the ‘Download Survey Materials’ page of the online survey).
Reporting Time Period: Answer questions #5-6 based on the most recent CMS 36-month report
published at www.HospitalCompare.hhs.gov.
Note: CMS updates the readmission rates for Heart Attack, Heart Failure, and Pneumonia annually in
July using a rolling 36-month reporting period. Hospitals that submit a survey prior to the CMS update in
July, are encouraged to come back into their survey to update the responses to this section.
5) Number of Pneumonia cases reported by CMS (in most recent 36-month
report)
If the number of cases reported by CMS is less than 25, skip Q6.
6) 30-day Risk Standardized Readmission Rate reported by CMS (in most
recent 36-month report)
Enter to one decimal place precision. Do not round.
Page 73
Version 6.1
______
______
(i.e. 23.5)
First Release: April 1, 2014
Updated Release: October 23, 2014
Resource Use for Common Acute
Conditions
2014 Leapfrog Hospital Survey
Affirmation of Accuracy:
As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated
responsibility, I have reviewed these statements pertaining to the Resource Use for Common Acute
Conditions section at our hospital, and I hereby certify that these statements are true, accurate, and
reflect the current, normal operating circumstances at our hospital. I am authorized to make this
certification on behalf of our hospital.
The hospital and I understand that The Leapfrog Group, its members and the public are relying on the
truth and accuracy of this information. The hospital and I also understand that The Leapfrog Group will
make this information and/or analyses of this information public through the survey results public
reporting website, The Leapfrog Group’s Hospital Safety Score, and/or other Leapfrog Group products
and services. This information and/or analyses and all intellectual property rights therein shall be the sole
and exclusive property of The Leapfrog Group. The hospital and I acknowledge that The Leapfrog Group
may use this information in a commercial manner for profit. The hospital shall be liable for and shall hold
harmless and indemnify The Leapfrog Group from any and all damages, demands, costs, or causes of
action resulting from any inaccuracies in the information or any misrepresentations in this Affirmation of
Accuracy. The Leapfrog Group and its participants reserve the right to omit or disclaim information that is
not current, accurate or truthful.
Affirmed by _____________________, the hospital’s ___________________________,
(name)
(title)
on _______________________.
(date)
Page 74
Version 6.1
First Release: April 1, 2014
Updated Release: October 23, 2014
Endnotes and “More Information”
2014 Leapfrog Hospital Survey
Endnotes and “More Information”
1
State
Your hospital is assigned to a state based on the Medicare Provider Number assigned (or identifier
specially issued by the Leapfrog Survey Help Desk) to your hospital. If your hospital is incorrectly
assigned to a state, contact the Help Desk to resolve the discrepancy.
2
Medicare Provider Number (MPN)
A Medicare Provider Number (MPN) is issued by the Centers for Medicare and Medicaid Services (CMS)
to financial reporting entities, which may be individual hospitals or a group of hospitals, for purposes of
reimbursement. While Leapfrog does ask each campus of a multi-hospital system to submit an individual
survey, hospitals within the system may be assigned the same Medicare Provider Number and therefore
should report the same MPN in this field. MPNs are six digits; with the first two digits represent the state
in which the hospital is located. Hospitals that do not receive Medicare reimbursement may not have a
Medicare Provider Number and should indicate 00-0000 in this field.
3
Tips for entering Web addresses
This address becomes the link attached to your hospital’s name in public release of survey results.
Enter it exactly as you wish it to be and test it.
 Do not exit out of the survey to go to the Web page of interest while you are entering data into the
survey or some of your survey entries may be lost.
 Instead, minimize (but don’t close) the survey window, and any other windows that are open, then
open your internet browser in a separate window. Find the Web page whose address you wish to
enter and Copy/Paste the entire address into the survey entry. Remove the http:// prefix from the
address!
 If entering the Web page address manually, be careful to type it correctly, without embedded spaces.
Forward (/) or backward (\) slashes may be used. Don’t forget the www. if that is part of the address.
 Make sure to use .org, rather than .com, if that’s the domain for your hospital’s Website. Remember
to remove the http:// prefix from the address!
 Test the address with the button in the survey form just below the entry.
 Although many hospitals elect to enter the address for the home page of their hospital Website,
consider pointing it to a page specific to patient safety, the Leapfrog safety practices, or other quality
improvement activities about which you want to communicate to your community.

4
Licensed Beds
If your state does not designate and license bed types, enter the number of staffed beds from question
10. Include short-term, acute-care medical, surgical, and obstetrical beds as licensed by your state.
Exclude beds licensed or used for long-term rehabilitation or psychiatric care, or sub-acute care, (e.g.,
skilled nursing facility (SNF), hospice extended care, sub-acute eating disorder treatment, extended care
facility, or residential substance abuse treatment). If the number of licensed beds has changed in the last
year, indicate the most recent number for which it is licensed.
5
Staffed Beds
Include licensed beds regularly in operation, whether currently occupied by a patient or not. If the number
has changed over the last year, indicate the average or other number most representative of your
operating bed capacity over the last year.
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6
Total Acute-Care Admissions
Include acute-care medical, surgical and obstetrical admissions to your hospital. Exclude long-term,
rehabilitation, short and long-term psychiatric, sub-acute care (e.g., skilled nursing facility (SNF), hospice
extended care, sub-acute eating disorder treatment, extended care facility, or residential substance abuse
treatment) admissions. Exclude normal newborn admissions to the nursery. Include transfers from other
hospitals as admissions to your hospital. Include any admissions directly to an ICU in your hospital, even
if counted in question 14.
7
Licensed ICU Beds
If your state separately designates ICU beds in its licensure, indicate the number of such beds currently
licensed this way. If your state does not designate and license ICU beds, enter the number of staffed
beds from question 13.
Include adult and pediatric general medical and surgical ICU beds as well as beds in neurology/
neurosurgery ICUs, but exclude Coronary Care Unit (CCU) beds if they are separately licensed and
operated. Do not include Neonatal Intensive Care Units, separate Trauma or Burn units, or beds in
intermediate care or step-down units. (If the same licensed ICU beds are used for both coronary intensive
care and other medical-surgical conditions, include them.) If the number licensed has changed over the
last year, indicate the most recent number for which it is licensed.
8
Staffed ICU Beds
Include ICU beds regularly in operation, whether currently occupied by a patient or not. If the number has
changed over the last year, indicate the average or other number most representative of your operating
ICU capacity over the last year.
Include adult and pediatric general medical and surgical ICU beds as well as beds in neurology/
neurosurgery ICUs, but exclude Coronary Care Unit (CCU) beds if they are separately licensed and
operated. Do not include Neonatal Intensive Care Units, separate Trauma or Burn units, or beds in
intermediate care or step-down units. (If the same licensed ICU beds are used for both coronary intensive
care as well as other medical-surgical conditions, include them.) If the number has changed over the last
year, indicate the average or other number most representative of your operating bed capacity in these
units over the last year.
9
ICU Admissions
Include admissions to adult or pediatric general medical and surgical ICU beds as well as beds in
neurology/ neurosurgery ICUs, whether directly admitted to the unit or transferred to the unit from another
area of your hospital, e.g., post-operatively. Count the number of hospitalizations that include an ICU
stay, not the number of patient trips to the ICU.
Ignore admissions to units dedicated exclusively to patients with highly specialized conditions -- e.g.,
ignore admissions to any Coronary Care Unit (CCU) that is distinct and separate from other
adult/pediatric general medical/surgical ICUs. (If the same ICU is used for both coronary intensive care as
well as other general medical-surgical conditions, include admissions to these units in your responses.)
Other examples of highly specialized units to ignore when responding are neonatal intensive care units,
separate trauma, burn, cardiovascular, or cardio-thoracic units. “Dedicated exclusively” means that
general med-surg patients are not also cared for in these specialized units (except in rare overflow
situations). Also ignore admissions or transfers to intermediate care or step-down units for this question.
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10
Council of Teaching Hospitals and Health Systems (COTH)
COTH is made up of teaching hospitals and health systems. More information about COTH is available at
https://www.aamc.org/members/coth/.
11
Teaching Hospital
Hospitals self-identified as a “teaching hospital” may have the following in place: a documented affiliation
agreement with a medical school; sponsor or participate in at least four approved, active residency
programs; and have at least two of the approved residency programs in medicine, surgery,
obstetrics/gynecology, pediatrics, family practice, or psychiatry.
12
Federal Tax Identification Number (TIN)
Enter the TIN that your hospital uses for billing purposes. The number is a nine-digit number with a
hyphen between the second and third digits, e.g., 09-8765432 and must conform precisely to this format.
Enter any leading 0 and the hyphen. If your hospital has more than one TIN, use the one that would most
typically be used for UB-92 claims filed with commercial health insurance plans for inpatient hospital
stays.
13
CPOE Linked to Pharmacy, Laboratory, ADT Information
The ability of a CPOE system to catch the majority of common, serious prescribing errors depends on
proper identification of patients (ADT information), current and recent pharmacy orders and drug
dispensing history, and access and integration of key laboratory results for the patient. CPOE systems
that are not linked to those other systems or do not reflect that current information accurately about the
patient are not likely to catch serious prescribing errors.
14
Post-Procedure Inpatient Deaths
Include in-hospital deaths for the patients included in the previous question, i.e., where the patient died
during the hospital stay that included that procedure. Count deaths following the specific surgery, whether
the death can be directly related to that procedure or not. Do not count deaths where the patient was
discharged alive following the surgery but died during a subsequent re-admission (unless the procedure
was repeated during that re-admission and the patient subsequently died during that stay).
For participants in STS or NNECDSG national or regional performance measurement systems, this
definition differs from “Operative Mortality” as used in those reporting systems, which include both inhospital and 30-day post-operative mortality out-of-hospital. (See endnotes below.)
15
Participation in STS or Performance Measurement Systems
If your hospital currently participates and has begun submitting data for all such procedures but has not
yet received any reports, you should indicate “Participating but no reports yet available". Return to the
survey and update answers to the remaining questions when you receive your hospital’s first reported
results.
16
Your Hospitals (Observed) Operative Mortality, Risk-adjusted Rate from STS Reports
For your hospitals most recent 12-month report, enter your hospital’s “Operative Mortality, Risk-adjusted
rate” for AVR (report p. AV Replace-62) in AVR Q5. This is your hospital’s actual operative mortality rate,
standardized (risk-adjusted) to the STS all-hospital risk. Operative Mortality, Risk-adjusted rate includes
in-hospital and 30-day post-operative mortality out-of-hospital.
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17
All STS Cohort (Expected) Operative Mortality, Risk-adjusted Rate from STS Reports
Enter the all-hospital STS cohort’s “Operative Mortality, Risk-adjusted rate” for AVR (report p. AV
Replace-62) in AVR Q6. This is the national expected operative mortality rate to which your hospital’s
observed rate in AVR Q5 will be compared. Operative mortality includes in-hospital and 30-day postoperative mortality out-of-hospital.
18
Mortality Results in Publicly Reporting States and Regional Registries
Hospitals located in a state with publicly reported outcomes should refer to the Outcome Specifications
in Section 3 of the Leapfrog Hospital Survey Reference Book (link found on the ‘Download Survey
Materials’ page of the online survey) to determine how they should report based on those reports. If you
are aware of publicly-reported results in these states for a more recent period, please contact the
Leapfrog Help Desk. Hospitals that participate in a regional registry should report their results from the
most recent report provided by the registry.
19
Observed Mortality Rates from Publicly Reported Outcomes and Regional Registries
Publicly Reported Outcomes: Follow the instructions in the Outcome Specifications in Section 3 of the
Leapfrog Hospital Survey Reference Book (link found on the home page of the online survey) to
determine the value to report for this question for your hospital.
NNECDSG reports: Please refer to the document titled “Leapfrog Hospital Survey Data” provided to you
as an addendum to your most recent NNECDSG Cardiac Surgery or PCI report.
20
Expected Mortality Rates from Publicly Reported Outcomes and Regional Registries
Publicly Reported Outcomes: Follow the instructions in the Outcome Specifications in Section 3 of the
Leapfrog Hospital Survey Reference Book (link found on the home page of the online survey) to
determine the value to report for this question for your hospital.
NNECDSG Reports: Please refer to the document titled “Leapfrog Hospital Survey Data” provided to you
as an addendum to your most recent NNECDSG Cardiac Surgery or PCI report.
21
High-Risk Deliveries Electively Admitted
Includes deliveries with:
 expected birth weight <1500 grams; or
 gestational age at least 22 weeks but <32 weeks.
Not all women at risk for delivery of babies with these conditions are known beforehand to be at risk.
Therefore, deliveries in which these high-risk conditions were unknown prior to admission are not
considered electively admitted high-risk deliveries.
If your hospital admits deliveries where these conditions are known prior to admission, then your hospital
electively admits high-risk deliveries and you should answer Yes to Question 1; otherwise, answer ‘No’.
22 Co-located with a Hospital Having a NICU
A hospital without a neonatal ICU but in immediate physical proximity to another hospital that has a
neonatal ICU, e.g., a children’s hospital next door to which your hospital immediately transfers all
complicated newborns, is considered as sharing a co-located NICU. "Immediate physical proximity”
means the two facilities must be physically connected, either by a tunnel, an enclosed bridge, or the
hospitals should about each other so that the hallways readily connect. Based on available research
evidence, the pivotal factor is that the neonatal team be able to attend the high-risk deliveries whenever a
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neonatal resuscitation might be necessary. If the hospitals are not immediately adjacent to each other,
this isn't possible.
23
Very-low birth weight babies
Complicated newborns are those infants with a birth weight <1500 grams. If your hospital has a neonatal
ICU (or is co-located with a hospital that has a neonatal ICU) that admits or accepts transfers of neonates
with these conditions, you should answer Yes to Question 2.
24
All Cases or a Sufficient Sample
If you have fewer than 60 cases that meet the criteria for inclusion in the denominator of the process
measure, include ALL of these cases in measuring adherence to the process indicators. You need NOT
use more than 12 months of historical experience to increase the eligible cases beyond 60; just measure
and report based on ALL eligible cases that you have in that period.
If you have more than 60 cases that meet those criteria during the time period of the audit, you may
sample 60 of them for the denominator of each indicator, and measure and report adherence based on
that sample. Specific sampling methodology for each measure is detailed in the Survey Reference Book.
25
Managed or Co-Managed
The intensivist, when present (whether on-site or via telemedicine), is authorized to diagnose, treat, and
write orders for a patient in the ICU on his/her own authority. Mandatory consults or daily rounds by an
intensivist are not sufficient to meet the managed/co-managed requirement. However, an ICU need not
be close-staffed to meet this requirement.
26
Certified in Critical Care Medicine
A physician who is “certified in Critical Care Medicine” is a board-certified physician who is additionally
certified in the subspecialty of Critical Care Medicine. Certification in Critical Care Medicine is awarded by
the American Boards of Internal Medicine, Surgery, Anesthesiology and Pediatrics.
Because sub-specialty certification is not offered in emergency medicine, emergency medicine physicians
will be considered “certified in Critical Care Medicine” if they are board-certified in emergency medicine
and have completed a critical care fellowship at an ACGME-accredited program.
On an interim basis, two other categories of physicians are considered by Leapfrog to be “certified in
Critical Care Medicine”:
 Physicians who completed training prior to availability of subspecialty certification in critical care
in their specialty (1987 for Medicine, Anesthesiology, Pediatrics, and Surgery), who are boardcertified in one of these four specialties, and who have provided at least six weeks of full-time ICU
care annually since 1987. (The weeks need not be consecutive weeks.)

Physicians board-certified in Medicine, Anesthesiology, Pediatrics, or Surgery who have
completed training programs required for certification in the subspecialty of Critical Care Medicine
but are not yet certified in this subspecialty.
Physicians who have finished their fellowship in Critical Care Medicine, but have not yet obtained board
certification are considered “Certified in Critical Care Medicine” for up to three years after completion of
the fellowship. This provides the physician an adequate window to take her/his boards and re-take if
necessary.
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Physicians who have let their board certification lapse are not considered to be “Certified in Critical Care
Medicine”.
“Neurointensivists” are classified as physicians who are board-certified in their primary specialty and who
have completed a UCNS-certified fellowship training program in neurocritical care, or a physician certified
by the UCNS in neurocritical care*. Existing physicians must obtain certification using the grandfathering
process established by UCNS to be considered a neurointensivist. This new category of intensivists
applies only to neuro ICUs. Neurointensivists qualify as “intensivists” only for coverage in neuro ICUs, not
in other ICUs.
27
Ordinarily and Exclusively Present in the ICU
“Ordinarily present in the ICU” refers to direct presence in the ICU (or presence via telemedicine) of an
intensivist during the 8-hour period. While it need not be the same intensivist for the entire 8-hour
duration, it is expected that the ICU(s) are primarily staffed by dedicated ICU intensivists who are
ordinarily and exclusively present in the ICU(s). "Presence" does not mean staffed part-time by multiple
physicians who are not ordinarily and exclusively dedicated to the ICU, nor does it mean the cumulative
time that one or more intensivists spend in the unit visiting, rounding, consulting, or responding to pages.
Note: To meet the Leapfrog ICU requirement for intensivist presence in the ICU via telemonitoring, a
hospital must affirm that its telemonitoring intensivist presence fulfills all 10 key features found in endnote
#30, including daily care planning by an on-site intensivist.
The standard allows for normally expected intensivist activities outside of the ICU related to their
responsibilities in the ICU (e.g. evaluating patients proposed for ICU admission), as long as intensivists
are ordinarily present in the ICU and return immediately when paged. An intensivist present in one ICU
immediately adjacent to another can be considered present in both units as long as s/he can respond to
demands in both units as if s/he would if both units were one larger unit. While tele-intensivists can be
used to meet the presence requirement, some on-site intensivist presence is still necessary to meet the
Leapfrog specifications.
Any intensivist, including a neurointensivist, ordinarily present in a neuro ICU meets this requirement for
that unit. However, presence of a neurointensivist in a general med-surg ICU (i.e., other than a dedicated
neuro ICU) cannot meet this requirement in those units.
“Exclusively” means that when the physician is in the ICU, s/he has no concurrent clinical
responsibilities to non-ICU patients.
28
Quantified Analysis of Pager Response Times
Providers can monitor pager response times in multiple ways, as long as the data collection process is
non-biased and scientific.
As an example . . .
Providers could maintain an exception log in the ICU(s) on six randomly sampled days per year. On those
days, ICU nurses could record:
 the number of urgent pages made to intensivists when they are not present in the unit (whether onsite 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.
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FCCS-Certified Nurse “Effector”
FCCS certificates are awarded to nurses and doctors upon their successful completion of a brief course
developed by the Society for Critical Care Medicine to improve/confirm critical care knowledge and skills.
For more information visit http://www.sccm.org/SCCM/FCCS+and+Training+Courses/. At present, this is
the only such course recommended by The Leapfrog Group’s expert advisory panel. Intensivists and any
other physicians who are certified in critical care medicine (or eligible based on residency training or
fellowship) need not also be FCCS certified. Physician assistants and nurse practitioners also are not
required to be FCCS certified.
29
Intensivist Presence via Telemedicine –
To meet the Leapfrog ICU requirement for intensivist presence in the ICU via telemonitoring, a hospital
must affirm that its telemonitoring intensivist presence fulfills the following 10 key features based on a
modification of the approach reported in Critical Care Medicine (Rosenfeld, B. et al. “Intensive care unit
telemedicine: Alternate paradigm for providing continuous intensivist care,” Critical Care Medicine, Vol.
28, No. 1, pp. 3925-3931.) Note that, as with other Leapfrog specifications, these features must be met
under ordinary circumstances.
30
1. An intensivist who is physically present in the ICU (“on-site intensivist) performs a comprehensive
review of each ICU patient each day and establishes and/or revises the care plan. The tele-intensivist
has immediate access to information regarding the on-site intensivist’ s care plan at the time
monitoring responsibility is transferred to him or her by the on-site intensivist. When care is
transferred back to the on-site intensivist, the tele-intensivist communicates (rounds) with the on-site
intensivist to review the patient’s progress and set direction.
2. When an intensivist is not on-site in the ICU managing or co-managing all ICU patients, a teleintensivist is monitoring and able to manage all ICU patients for the remaining 24 hours per day,
7 days per week. “Monitoring” means the tele-intensivist has no other concurrent responsibilities, is
immediately available to communicate with ICU staff, and is in the physical presence of the tele-ICU’s
patient monitoring and communications equipment. "Manage" means authorized to diagnose, treat,
and write orders for a patient in the ICU on his/her own authority.
3. A tele-intensivist has immediate access to key patient data, including:
a) physiologic bedside monitor data (in real-time);
b) laboratory orders and results;
c) medications ordered and administered; and,
d) notes, radiographs, ECGs, etc. on demand.
4. Data links between the ICU and the tele-intensivist are reliable (>98% up-time) and secure (HIPAA
compliant).
5. Via A-V support, tele-intensivists are able to visualize patients with sufficient clarity to assess
breathing pattern, and communicate with on-site personnel at the bedside in real time.
6. Written standards for remote care are established and include, at a minimum:
a) tele-intensivists are certified by a national medical specialty board in critical care medicine;
b) tele-intensivists are licensed to practice in the legal jurisdiction in which the ICU is located;
c) tele-intensivists are credentialed in each hospital to which he/she provides remote care (can be
special telemedicine credentialing);
d) activities of the tele-intensivist are reviewed within the hospital’s quality assurance committee
structure;
e) there are explicit policies regarding roles and responsibilities of both the on-site intensivist and
the tele-intensivist; and,
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f)
there is a process for educating staff regarding the function, roles, and responsibilities of the
tele-intensivist.
7. Tele-ICU care is proactive, with routine review of all patients at a frequency appropriate to their
severity of illness.
8. A tele-intensivist’s patient workload ordinarily permits him or her to complete a comprehensive
assessment of any patient within five minutes of the request for assistance being initiated by hospital
staff.
9. There is an established written process to ensure effective communication between the on-site care
team and the tele-intensivist.
10. The tele-intensivist documents patient care activities and this documentation is incorporated into the
patient record.
31
Adult or Pediatric, General Medical and/or Surgical ICUs or Neuro ICUs
The IPS standard applies only to adult and pediatric general medical and/or surgical ICUs and neuro
ICUs. When responding to this section, ignore units dedicated exclusively to patients with other highly
specialized conditions. E.g., ignore any Coronary Care Unit (CCU) that is distinct and separate from other
adult/pediatric general medical/surgical ICUs. (If the same ICU is used for both coronary intensive care as
well as other general medical-surgical conditions, include this unit in your responses.) Other examples of
highly specialized units to ignore when responding are: neonatal intensive care units, separate trauma,
burn, cardiovascular, or cardio-thoracic. “Dedicated exclusively” means that general med-surg patients
are not also cared for in these specialized units (except in rare overflow situations). If they are, then the
IPS standard applies to those units as well. Also ignore intermediate care or step-down units when
responding to this section.
32
All Patients Managed or Co-managed by Intensivist
“Managed or co-managed” means that the intensivist, when present (on-site or via telemedicine), is
authorized to diagnose, treat, and write orders for a patient in the ICU in his/her own authority. Mandatory
consults or daily rounds by an intensivist are not sufficient to meet the managed/co-managed
requirement. However, to meet this requirement, an ICU need not be “closed”, i.e., the intensivist
becomes the attending of record during the patient’s ICU stay.
“All patients” means any patient in the ICU.
“Physician certified in critical care medicine” (intensivist) means a board-certified physician who is
additionally certified in the subspecialty of Critical Care Medicine. Certification in Critical Care Medicine is
awarded by the American Boards of Internal Medicine, Surgery, Anesthesiology and Pediatrics.
Because sub-specialty certification is not offered in emergency medicine, emergency medicine physicians
are considered certified in critical care if they are board-certified in emergency medicine and have
completed a critical care fellowship at an ACGME-accredited program.
On an interim basis, two other categories of physicians are considered by Leapfrog to be “certified in
Critical Care Medicine”:
 Physicians who completed training prior to availability of subspecialty certification in critical care
in their specialty (1987 for Medicine, Anesthesiology, Pediatrics and Surgery), who are board-
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
certified in one of these four specialties, and who have provided at least six weeks of full-time ICU
care annually since 1987. (The weeks need not be consecutive weeks.)
Physicians board-certified in Medicine, Anesthesiology, Pediatrics or Surgery who have
completed training programs required for certification in the subspecialty of Critical Care Medicine
but are not yet certified in this subspecialty.
If you can answer Yes to question #2, but only if some or all of the physicians considered intensivists fall
under these two interim definitions, answer “Yes, based on expanded definition of certified”.
Note: Physicians who have finished their fellowship in Critical Care Medicine, but have not yet obtained
board certification are considered “Certified in Critical Care Medicine” for up to three years after
completion of the fellowship. This provides the physician an adequate window to take her/his boards and
re-take if necessary. Physicians who have let their board certification lapse are not considered to be
“Certified in Critical Care Medicine”.
For neuro ICUs, the definition of a physician “certified in critical care medicine” would be extended to
include neurointensivists. Neurointensivists are defined as neurologists and neurological surgeons who
are board-certified in their primary specialty and who has completed a UCNS-certified fellowship training
program in neurocritical care, or a physician who is board certified in neurocritical care. This alternative
definition of “certified in critical care medicine” is only applicable to neuro ICUs.
33
Modified Intensivist Presence via Telemedicine
To earn reduced credit on the Leapfrog ICU standard for intensivist presence in the ICU via
telemonitoring, a hospital must affirm that its telemonitoring intensivist presence fulfills the following nine
key features based on a modification of the approach reported in Critical Care Medicine (Rosenfeld, B. et
al. “Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care,” Critical
Care Medicine, Vol. 28, No. 1, pp. 3925-3931.) Note that, as with other Leapfrog specifications, these
features must be met under ordinary circumstances.
1. When an intensivist is not on-site in the ICU managing or co-managing all ICU patients, a teleintensivist is monitoring and able to manage all ICU patients for the remaining 24 hours per day,
7 days per week. “Monitoring” means the tele-intensivist has no other concurrent responsibilities, is
immediately available to communicate with ICU staff, and is in the physical presence of the tele-ICU’s
patient monitoring and communications equipment. "Manage" means authorized to diagnose, treat,
and write orders for a patient in the ICU on his/her own authority.
2. A tele-intensivist has immediate access to key patient data, including:
a) physiologic bedside monitor data (in real-time);
b) laboratory orders and results;
c) medications ordered and administered; and,
d) notes, radiographs, ECGs, etc. on demand.
3. Data links between the ICU and the tele-intensivist are reliable (>98% up-time) and secure (HIPAA
compliant).
4. Via A-V support, tele-intensivists are able to visualize patients with sufficient clarity to assess
breathing pattern, and communicate with on-site personnel at the bedside in real time.
5. Written standards for remote care are established and include, at a minimum:
a) tele-intensivists are certified by a national medical specialty board in critical care medicine;
b) tele-intensivists are licensed to practice in the legal jurisdiction in which the ICU is located;
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c)
d)
e)
f)
tele-intensivists are credentialed in each hospital to which he/she provides remote care (can be
special telemedicine credentialing);
activities of the tele-intensivist are reviewed within the hospital’s quality assurance committee
structure;
there are explicit policies regarding roles and responsibilities of both the on-site intensivist and
the tele-intensivist; and,
there is a process for educating staff regarding the function, roles, and responsibilities of the
tele-intensivist.
6. Tele-ICU care is proactive, with routine review of all patients at a frequency appropriate to their
severity of illness.
7. A tele-intensivist’s patient workload ordinarily permits him or her to complete a comprehensive
assessment of any patient within five minutes of the request for assistance being initiated by hospital
staff.
8. There is an established written process to ensure effective communication between the on-site care
team and the tele-intensivist.
9. The tele-intensivist documents patient care activities and this documentation is incorporated into the
patient record.
34
Teamwork Training
Teamwork training subject matter includes: sources of communication failures, hand-offs, and team
failures that lead to patient harm. Participation should be documented.
35
American Nurses Credentialing Center (ANCC) Magnet ® Organizations
For a list of hospitals that are currently recognized as Magnet organizations, please see ANCC’s website
at: http://www.nursecredentialing.org/Magnet/FindaMagnetFacility.aspx
36
Never Event
In 2011, the National Quality Forum released a list of 29 events that they termed “serious reportable
events”, extremely rare medical errors that should never happen to a patient. Often termed “never
events”, these include errors such as surgery performed on the wrong body part or on the wrong patient,
leaving a foreign object inside a patient after surgery, or discharging an infant to the wrong person. This is
an update of NQF’s original 2002 and 2006 reports. Please see NQF’s “Never Events list at
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=69573. Hospitals may not
earn credit for this question if they have only implemented a policy that includes the Center for Medicare
and Medicaid (CMS) Never Events.
37
Apology to the Patient
While Leapfrog recognizes that on very rare occasions 'never events' can occur that are not the fault of
care systems or clinical care staff, given the high level of trust patients place in health care providers,
Leapfrog feels it is appropriate for caregivers to apologize when a patient within their care setting suffers
a serious event.
As the National Quality Forum identified in their 2002, 2006, and 2011 Serious Reportable Events Report,
given the serious nature of these events, it is reasonable for hospitals to initially assume that the adverse
event was due to the referenced course of care. And while further investigation and/or root cause
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analysis of the unplanned event may be needed to confirm or refute the presumed relationship, delaying
an apology to the patient is not treating the patient with compassion and sympathy.
Reporting Never Events to External Agencies –
If your hospital is not a Joint Commission accredited hospital, is located in a state without a state-wide
reporting program for medical errors, AND there is no available Patient Safety Organization to which your
hospital can report medical errors, the hospital should report the event to the Board of Trustees. Full
implementation of the Never Events policy still requires the hospital to conduct a root cause analysis of
the event.
38
39
Root Cause Analysis
The state of Minnesota has developed an online RCA toolkit designed to be a resource for any hospital
that would like to establish or improve their RCA process. The toolkit can be found at:
http://www.health.state.mn.us/patientsafety/toolkit/index.html
40
Operating an on-site ICU
Hospitals should answer “Yes” if they operate an on-site ICU. Hospitals that use teleintensivist services to
monitor their ICUs are still considered as operating an on-site ICU. Hospitals that use teleintensivist
services to monitor their ICUs may need to work with their teleintensivist service to obtain the required
data points to complete these measures.
41
Trained in Human Factors Engineering
Personnel trained in human factors engineering include those persons with formal training in human
factors engineering, human factors, ergonomics, or human engineering. Their training includes a focus
on the interaction between the human and the system, including the work environment, tools, and
computer systems.
42
Major Teaching Hospital
A hospital is identified as a major teaching hospital if it achieves a minimum ratio of one resident (i.e.
physician in training) per four staffed inpatient beds; or, the hospital has self-designated as a major
teaching hospital to the CDC NHSN.
43
Operating an on-site ICU
Hospitals should answer “Yes” if they operate an on-site ICU. Hospitals that use teleintensivist services to
monitor their ICUs are still considered as operating an on-site ICU. Hospitals that use teleintensivist
services to monitor their ICUs may need to work with their teleintensivist service to obtain the required
data points to complete these measures.
44
Major Teaching Hospital
A hospital is identified as a major teaching hospital if it achieves a minimum ratio of one resident (i.e.
physician in training) per four staffed inpatient beds; or, the hospital has self-designated as a major
teaching hospital to the CDC NHSN.
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This is the last page of the hard copy of the Leapfrog Hospital Survey.
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 your Leapfrog Hospital Survey Results at www.leapfroggroup.org/cp.
Be sure to print a copy of your Last Submitted Survey. Review the print out for accuracy
and completeness, and retain a copy for your records. If you make any updates to your
survey, remember to re-affirm updated sections and re-submit the entire survey.
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