SUMMARY OF CHANGES TO THE 2018 LEAPFROG HOSPITAL SURVEY & RESPONSES TO PUBLIC COMMENTS

Transcription

1 SUMMARY OF CHANGES TO THE 2018 LEAPFROG HOSPITAL SURVEY & RESPONSES TO PUBLIC COMMENTS PUBLISHED MARCH 23, 2018 Each year, The Leapfrog Group s team of researchers, in conjunction with the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, review literature and convene national expert panels to ensure the Leapfrog Hospital Survey aligns with the latest science as well the public reporting needs of purchasers and consumers. We assemble a list of proposed changes for the next year s Survey and release those changes for a 30-day public comment period. Comments are reviewed carefully and used to further refine the Survey. The Survey is then pilot tested with a diverse group of hospitals across the country. Following the pilot test, Survey content and scoring are finalized for launch on April 1. Leapfrog received over 150 public comments in response to its proposed changes for the 2018 Leapfrog Hospital Survey. Those comments, as well as the results from the pilot test, were incorporated into the final content and scoring algorithms for the Survey. We have summarized the changes in this document, and included summaries and responses to public comments in Appendix I. We offer our sincere gratitude to all commenters for the time and thought they gave to the 2018 Leapfrog Hospital Survey. The submitted comments were invaluable to the development of a high-quality Survey that serves our many constituents, including purchasers and payers, as well as hospitals and the public at large. The 2018 Survey will open on April 1, Leapfrog has already scheduled a number of informative Town Hall Calls. Hospitals and other stakeholders can register on the Town Hall Calls webpage. 1

2 CONTENT AND SCORING CHANGES SECTION 1: BASIC HOSPITAL INFORMATION To ensure accurate reporting of pediatric admissions, Leapfrog updated the endnote describing the criteria for pediatric admissions to include pediatric admissions (i.e. <18 years of age) to any inpatient unit, not just dedicated pediatric units. Hospitals are instructed to exclude normal newborn admissions to the nursery and pediatric patients admitted for maternity care, behavioral health, or discharged to hospice when reporting on pediatric admissions. To ensure consistency with other national data sources, Leapfrog will obtain teaching status directly from the 2017 NHSN Annual Hospital Survey - Patient Safety Component for those hospitals that join Leapfrog s NHSN Group, provide a valid NHSN ID in the Profile, and submit Section 1. Hospitals designated as Major Teaching or Graduate will be designated as teaching hospitals for the purposes of the Leapfrog Hospital Survey. Teaching status is not used in scoring, but is used to designate hospitals for the purposes of the Top Hospital Program. Find instructions on how to join Leapfrog s NHSN Group and deadlines for the 2018 Survey on the Join NHSN Group webpage. SECTION 2: MEDICATION SAFETY - COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) Based on feedback received during the Pilot Test, Leapfrog has added measure specifications for both questions #3 (total number of inpatient medication orders across all units, including those without CPOE) and question #4 (total number of those inpatient medication orders included in question #3 that were entered via a qualified CPOE system) for clarity. Leapfrog is implementing three updates to the CPOE Scoring Algorithm: We are increasing the target for implementation status (i.e. percentage of inpatient orders entered through an inpatient CPOE system) from 75% to 85%. This increase will be applied to both adult/general hospitals and pediatric hospitals. We are increasing the target for the score on the Adult Inpatient Test via the CPOE Evaluation Tool from 50% to 60%. To achieve Full Demonstration of National Safety Standard for Decision Support in 2018, hospitals must demonstrate that its inpatient CPOE system alerts prescribers to at least 60% of common serious ordering errors. We are updating the way in which the two elements of the standard (implementation status and Adult Inpatient Test score from the CPOE Evaluation Tool) are combined together to result in an overall CPOE Score for adult/general hospitals. In order to be scored as Fully Meets the Standard in 2018, hospitals will need to have the top CPOE test score ( Full Demonstration of National Safety Standard for Decision Support ) and have one of the top two implementation statuses (85% or greater or 75-84%). Please see Appendix II for additional updates to the Adult CPOE Scoring Algorithm and a description of the order checking categories included in the CPOE Evaluation Tool (v3.5). Currently, there is no CPOE test available for pediatric hospitals. Therefore, pediatric hospitals will need to have the top implementation status (85% or greater) in order to be scored as Fully Meets the Standard. SECTION 3: INPATIENT SURGERY (APPLICABLE TO ADULT/GENERAL HOSPITALS ONLY) 2

3 SECTION 3A: HOSPITAL AND SURGEON VOLUME STANDARD Based on minimum hospital and surgeon volume standards first published in 2015 by researchers at Dartmouth-Hitchcock Medical Center, Michigan Medicine (University of Michigan) and Johns Hopkins Medicine, as well as information collected in 2017 from the Leapfrog Hospital Survey, peer-reviewed literature, and consultation with national experts, Leapfrog is implementing the following hospital and surgeon volume standards for 2018: Procedure Hospital Volume (minimum per 12-months or 24- month annual average) Surgeon Volume (minimum per 12-months or 24- month annual average) Bariatric surgery for weight loss Esophageal resection for cancer 20 7 Lung resection for cancer Pancreatic resection for cancer Rectal cancer surgery 16 6 Carotid endarterectomy Open abdominal aortic aneurysm repair Mitral valve repair and replacement Hospitals will be asked to report on their total hospital volume over a 12-month period or their annual average over a 24- month period based on updated procedures and diagnosis codes that include several recommendations from participating hospitals and health systems. Hospitals can download an Excel Workbook which includes the list of procedure and diagnosis codes on the Survey and CPOE Materials webpage beginning April 1. In addition, the list of high-risk procedures has been reduced from ten to eight. Leapfrog has eliminated total hip and total knee replacement for the 2018 Survey to allow for additional time in finalizing the recommended hospital and surgeon volume standards. We are removing the individual surgeon volume questions due to the challenges hospitals reported in obtaining accurate volume data on surgeons that perform that surgery at multiple facilities. Instead, hospitals will be asked whether their process for privileging surgeons requires that the surgeon meet or exceed the minimum surgeon volume standards listed in the table above. See the updated questions below: 1) Check all procedures that your hospital performs as defined in the Inpatient Surgery Reference Information. If your hospital does not perform the procedure, or ONLY does so when a patient is too unstable for safe transfer, OR ONLY when a procedure is urgent or emergent, do not check the box next to that procedure. If None of the above, please skip remaining questions in Section 3A and 3B, and go to the Affirmation of Accuracy. Carotid endarterectomy Mitral valve repair and replacement Open abdominal aortic aneurysm repair Lung resection for cancer Esophageal resection for cancer Pancreatic resection for cancer Rectal cancer surgery Bariatric surgery for weight loss None of the above Hospitals will only respond to questions #2 and #3 based on the procedures selected in question #1. 2) Total hospital volume for each selected procedure during the reporting period: 3

4 Procedure Carotid endarterectomy Mitral valve repair and replacement Open abdominal aortic aneurysm repair Lung resection for cancer Esophageal resection for cancer Pancreatic resection for cancer Rectal cancer surgery Bariatric surgery for weight loss Number of Procedures Performed (12-month count or 24-month annual average) 3) Does your hospital s process for privileging surgeons include the surgeon meeting or exceeding the minimum surgeon volume standard listed below? Procedure Surgeon Volume Standard Carotid endarterectomy 10 Mitral valve repair and replacement 20 Open abdominal aortic aneurysm repair 10 Lung resection for cancer 15 Esophageal resection for cancer 7 Pancreatic resection for cancer 10 Rectal cancer surgery 6 Bariatric surgery for weight loss 20 Yes No Plan to implement within 12 months Yes No Plan to implement within 12 months Yes No Plan to implement within 12 months Yes No Plan to implement within 12 months Yes No Plan to implement within 12 months Yes No Plan to implement within 12 months Yes No Plan to implement within 12 months Yes No Plan to implement within 12 months Scoring Algorithm for the Minimum Hospital and Surgeon Volume Standard Hospital and Surgeon Volume Standard Score (Performance Category) Fully Meets the Standard (four-filled bars) For each of the surgeries performed by the hospital The hospital met the minimum hospital volume standard for the surgery; and 4

5 Substantial Progress (three-filled bars) Some Progress (two-filled bars) Willing to Report (one-filled bar) Does Not Apply Declined to Respond The hospital s process for privileging surgeons includes meeting or exceeding the minimum surgeon volume standard. The hospital met the minimum hospital volume standard for the surgery; and The hospital s process for privileging surgeons does not include meeting or exceeding the minimum surgeon volume standard, but the hospital is committed to doing so within the next 12 months. The hospital did not meet the minimum hospital volume standard for the surgery, but the hospital s process for privileging surgeons includes meeting or exceeding the minimum surgeon volume standard; OR The hospital met the minimum hospital volume standard for the surgery, but the hospital s process for privileging surgeons does not include the minimum surgeon volume standard, and the hospital is not committed to doing so within the next 12 months. The hospital did not meet the minimum hospital volume standard for the surgery; and The hospital does not include the minimum surgeon volume standard in its privileging policy, whether or not they are committed to doing so in the next 12 months. The hospital does not perform the surgery. The hospital did not respond to the questions in this section of the survey or did not submit a survey. SECTION 3B: SURGICAL APPROPRIATENESS Questions in this section focus on the hospital s progress in developing appropriateness criteria based on published guidelines and input from local surgeons, supporting and monitoring adherence, as well as communicating with surgeons, hospital leaders, and board members about adherence to the criteria. In 2018, responses to this subsection will be publicly reported but not scored by Leapfrog. When visitors to Leapfrog s public reporting website click the score icon for the surgical volume standard (i.e. four filled bars, three filled bars, etc.), they will see a statement indicating whether the hospital has processes and protocols in place to ensure surgical appropriateness. Hospitals that respond Yes to all five questions specific to that surgery will be reported as Yes and hospitals that respond No to one or more of the five questions will be reported as Not Yet. This approach aims to encourage hospitals to continue implementing processes and protocols to ensure surgical appropriateness while giving them additional time before the responses are used in scoring, planned for SECTION 4: MATERNITY CARE There are no changes to the questions in this section. However, there are important updates to the data specifications. For hospitals that do not submit data to The Joint Commission (TJC) and need to retrospectively collect data using the TJC specifications provided, two of the three TJC measures included in Section 4, Early Elective Deliveries (PC-01) and NTSV C-sections (PC-02), will use multiple TJC measure specifications based on the discharge dates of included cases due to updates between each version: 5

6 v2016b1: Discharges between 01/01/ /30/2017 v2017a1: Discharges between 07/01/ /31/2017 v2017b1: Discharges between 01/01/ /30/2018 Please be sure to refer to the correct specification manual for the discharge date if using TJC measure specifications as there have been updates to the ICD-10 tables and data elements between releases, including the addition of history of stillbirth in v2017a1 and v2017b1 as an exclusion for Early Elective Deliveries (PC-01). The Antenatal Steroids (PC-03) measure will only use one set of TJC measure specifications (v2017a1) for both reporting periods since there were no updates between the releases. SECTION 5: ICU PHYSICIAN STAFFING (IPS) Leapfrog has made minor updates to the wording of some of the questions and response options in Section 5 ICU Physician Staffing to better understand hospitals use of tele-intensivists. In addition, in 2018, Questions #7 and #8 will not be included in the scoring criteria for the Some Progress (i.e. two-filled bars) performance category. This change will ensure consistency between responses to Question #3, which asks if all patients in these ICUs are at any time managed or co-managed by one or more physicians certified in critical care medicine either on-site or via telemedicine, and Questions #7 and/or #8, which asks how much time patients are managed or comanaged by intensivists either on-site or via telemedicine. Please see Appendix III for the 2018 IPS Scoring Algorithm. SECTION 6: NQF SAFE PRACTICES SCORE Due to the absence of national training/educational opportunities to support managers in integrating risk and hazard information, Leapfrog is removing Safe Practice element 4.3.c, which is listed below, from Safe Practice 4 Risks and Hazards. No updates to the scoring or weight for Safe Practice 4 Risks and Hazards are proposed. In regard to developing the ability to appropriately assess risk and hazards to patients, the organization has done the following or had in place during the last 12 months: Senior managers have received training in the integration of risk and hazard information across the organization. Training was documented. (pp ) Instructions for reporting on Safe Practices in Section 6 have been updated to include information about collecting key documentation to support each answer, as Leapfrog s verification process includes a review of safe practices documentation from a random selection of hospitals every month during the survey cycle (April 1 to December 31). Leapfrog would like to thank those organizations that provided feedback on the addition of two unscored, fact-finding questions in Safe Practice 19 Hand Hygiene related to the use of electronic hand hygiene and/or video monitoring systems. Leapfrog will not be adding these two unscored questions to Safe Practice 19 in We are convening a national expert panel to develop an evidence-based structural measure that represents the best practices in hand hygiene monitoring and compliance and envision this new measure replacing Safe Practice 19 in the future. 6

7 SECTION 7: MANAGING SERIOUS ERRORS SECTION 7A: NEVER EVENTS POLICY STATEMENT Based on comments received during the public comment period, Leapfrog has made two minor updates to Section 7A which were not originally proposed. First, we will update the wording of each practice statement to indicate fact rather than intent. For example, the current policy states that we will apologize to the patient and/or family effected by the never event and will be updated to state, we apologize to the patient and/or family effected by the never event. Next, we have updated the number of days that hospitals are required to report the never event from 10 days to 15 business days. This is consistent with the Minnesota Department of Health s Adverse Event Reporting Systems, which has been cited by experts as a national model for reporting adverse events. More information can be found here. Leapfrog will implement the following scoring algorithm for Section 7A Never Events which includes the four (4) new principles added in These results will be publicly reported in Never Events Score (Performance Category) Fully Meets the Standard (four-filled bars) Substantial Progress (three-filled bars) Some Progress (two-filled bars) Willing to Report (one-filled bar) Declined to Respond Description The hospital has implemented a policy that adheres to all 9 principles of The Leapfrog Group s Policy Statement on Serious Reportable Events/ Never Events. The hospital has implemented a policy that adheres to all of the original 5 principles of The Leapfrog Group s Policy Statement on Serious Reportable Events/ Never Events, as well as at least 2 additional principles. The hospital has implemented a policy that adheres to all of the original 5 principles of The Leapfrog Group s Policy Statement on Serious Reportable Events/ Never Events. The hospital responded to the Leapfrog Hospital Survey questions pertaining to adoption of this policy, but does not yet meet the criteria for Some Progress. The hospital did not respond to the questions in this section of the Survey or did not submit a Survey. SECTION 7B: HEALTHCARE-ASSOCIATED INFECTIONS There are no changes to this subsection. We are pleased that hospital feedback regarding Leapfrog s removal of burdensome questions related to healthcareassociated infections has been overwhelmingly positive. Therefore, in 2018, Leapfrog will again draw infections data directly from the National Healthcare Safety Network (NHSN). To do so, hospitals must join Leapfrog s NHSN Group, provide a valid NHSN ID in their Leapfrog Hospital Survey Profile, and submit Section 7 of the Leapfrog Hospital Survey by the designated deadlines. This is all that is necessary to be scored and publicly reported on the five infection measures: CLABSI, CAUTI, MRSA, C. Diff. and SSI Colon. There are no changes to the scoring algorithm for this section. 7

8 SECTION 7C: HOSPITAL-ACQUIRED CONDITIONS PRESSURE ULCERS AND INJURIES Due to feedback Leapfrog received from hospitals in 2017 regarding the feasibility of using the updated ICD-10 measure specifications to report on the hospital-acquired pressure ulcers and injuries measures, Leapfrog is removing Section 7C Hospital-Acquired Conditions Pressure Ulcers and Injuries from the 2018 Survey. SECTION 7D: ANTIBIOTIC STEWARDSHIP PRACTICES We are pleased that hospitals will no longer need to devote time to responding to questions in Section 7D. Instead, Leapfrog will obtain information regarding the hospital s implantation of antibiotic stewardship practices directly from CDC s National Healthcare Safety Network (NHSN). Hospitals will be required to join Leapfrog s NHSN Group, provide a valid NHSN ID in their Leapfrog Hospital Survey Profile, and submit Section 7 of the Leapfrog Hospital Survey by the designated deadlines in order to be scored and publicly reported on the Antibiotic Stewardship Practices measure. There are no changes to the scoring algorithm for this section. SECTION 8: MEDICATION SAFETY PROPOSED CHANGES TO SECTION 8A BAR CODE MEDICATION ADMINISTRATION In Section 8A BCMA, Question #15a 15e, hospitals currently report if they have any of five Processes and Structures to Prevent Workarounds: a. Has a formal committee that meets routinely to review data reports on BCMA system use b. Has back-up systems for BCMA hardware failures c. Has a Help Desk that provides timely responses to urgent BCMA issues in real-time d. Conducts real-time observations of users using the BCMA system e. Engages nursing leadership at the unit level on BCMA use Leapfrog has added three additional processes to this question in the 2018 Survey: Which of the following has your hospital done with the data and information identified through items a-e above: f. In the past 12 months, used the data and information obtained through items a-e to implement quality improvement projects that have focused on improving the hospital s BCMA performance OR In the past 12 months, used the data and information obtained through items a-e to monitor a previously implemented quality improvement project focused on improving the hospital s BCMA performance g. In the past 12 months, evaluated the results of the quality improvement projects (from f) and demonstrated that these projects have resulted in higher adherence to our hospital s standard medication administration process OR In the past 12 months, evaluated the results of the quality improvement projects (from f) and demonstrated continued adherence to your hospital s standard medication administration process 8

9 h. Communicated back to end users the resolution of system deficiencies and/or problems that may have contributed to the workaround. To meet the Processes and Structures to Prevent Workarounds component of the BCMA standard, hospitals would need to respond yes to 6 out of 8 questions above. No other updates are proposed for Section 8A BCMA. Please see Appendix IV for the 2018 IPS Scoring Algorithm. PROPOSED CHANGES TO SECTION 8B MEDICATION RECONCILIATION (APPLICABLE TO ADULT/GENERAL HOSPITALS ONLY) In 2017, Leapfrog added a new NQF-endorsed medication reconciliation measure: Number of Unintentional Medication Discrepancies per Patient (NQF 2456). The measure focuses on the quality and accuracy of the hospital s medication reconciliation process. The measure is developed for adult inpatients only, but Leapfrog continues to advocate for an adaptation for pediatric patients. The data collection protocols in the measure are effective for hospitals quality improvement and the measure stewards provide significant free resources and information for hospitals to implement these protocols. Information about the significant impact of poor medication reconciliation is available on Leapfrog s website. Hospitals were not scored or publicly reported on this measure in In 2018, Leapfrog will address feedback received from hospitals in First, Leapfrog will give hospitals two options for meeting the data collection requirements for this measure: Hospitals that started and have continued to sample 10 patients on a quarterly basis using the 2017 Leapfrog Hospital Survey measure specifications can use those data when reporting on this section of the Survey. Hospitals that did not start sampling patients in 2017, can sample in real-time (i.e. after April 1) and start data collection anytime during the survey cycle by sampling 15 patients. Next, we will limit sampling for the measure to patients admitted to medical/surgical units only. Lastly, we made the following updates to the data collection instructions: Standard language that pharmacists can use to inform patients selected for the measure that the pharmacist is not normally part of the patient s care team, but interviewing the patient to ensure that the hospital s medication reconciliation process is accurate. Instructions on how to record unintentional discrepancies that have been corrected prior to the patient s discharge. Pharmacists are expected to intervene upon identification of an error on the admission or discharge orders (i.e. discrepancy between the Gold Standard Medication History the pharmacist obtained from the patient and the admission or discharge orders), and these discrepancies should still be recorded in the measure. Hospitals will continue to report the number of unintentional medication discrepancies identified between the Gold Standard Medication History obtained by a trained pharmacist and the admission and discharge orders, including the number of additional unintentional medications. Hospitals who submit this section of the 2018 Leapfrog Hospital Survey, and whose responses are not flagged during Leapfrog s monthly data review, will be scored as Fully Meets the Standard for having a protocol in place to collect data 9

10 on the accuracy of the hospital s medication reconciliation process. Hospitals that submit this section, but whose responses are flagged during Leapfrog s monthly data review for potential data entry errors, will be scored as Willing to Report for beginning to put a protocol in place to collect data on the accuracy of the hospital s medication reconciliation process. Hospitals that do not submit this section will be scored as Declined to Respond. In 2018, Leapfrog does not intend to publicly report a hospital s rate of unintentional medication discrepancies per patient. SECTION 9: PEDIATRIC CARE SECTION 9A: CAHPS CHILD HOSPITAL SURVEY Hospitals with at least 500 annual pediatric inpatient admissions (patients <18 years of age) to any unit (adult or pediatric, including any level ICU) will be asked to administer the CAHPS Child Hospital Survey or be publicly reported as Declined to Respond. Next, hospitals with at least 100 returned CAHPS Child Hospital Surveys will be asked to report their Top Box Score for each of the 18 domains of patient experience. Hospitals that are administering the survey, but had fewer than 100 returned surveys will be reported as Unable to Calculate Score. Results from this section will be scored and publicly reported in Based on additional feedback from stakeholders received after the Proposed Changes were published, Leapfrog will publicly report the Top Box Scores for all 18 domains, but calculate the performance category based on five (5) of the domains, rather than the nine (9) as originally proposed. Those five will include: Communication with Parents Communication about your child s medicines Communication with Parents Keeping you informed about your child s care Communication with Children How well nurses communicate with your child Communication with Children How well doctors communicate with your child Attention to Safety and Comfort Preventing mistakes and helping you report concerns Quartile values for each of the 5 domains listed above will be calculated based on the range of hospital performance reported on 2018 Leapfrog Hospital Surveys submitted by June 30. Hospitals will receive points for each of the 5 domains based on how they compare to the quartile cut-points. Hospitals that perform in the top quartile will receive 4 points for that domain; those that perform in the 3rd quartile will receive 3 points, etc. Then, the percentage of points earned over all domains is calculated to determine the overall performance category. The percentage of points required for each of the four performance categories (i.e. Fully Meets the Standard, Substantial Progress, etc.) will be determined by the distribution of total points earned using Surveys submitted by June 30. SECTION 9B: PEDIATRIC COMPUTED TOMOGRAPHY (CT) RADIATION DOSE Leapfrog will limit reporting to head scans and abdomen/pelvis scans given the low frequency of chest and chest/abdomen/pelvis scans observed in the 2017 Survey. Based on feedback received after the Proposed Changes were published and concerns about very low median dose values, Leapfrog will continue to ask hospitals to report their 25 th, 50 th, and 75 th percentile dose values (DLP) for head scans and abdomen/pelvis scans in the five age ranges. 10

11 Hospital responses will be scored and publicly reported for head scans and abdomen/pelvis scans separately. Leapfrog will score this section of the Survey by comparing the hospital s median dose for each anatomic region and age stratum to two benchmarks. The first benchmark is the Median Benchmark, which will be the median of the median doses reported across all Leapfrog-reporting hospitals as of June 30, The second benchmark is the median of the 75 th percentile doses reported across all Leapfrog-reporting hospitals as of June 30, Hospitals will receive points based on their reported median dose compared to the benchmarks. If the hospital s reported median dose is less than the Median Benchmark, it will receive 2 points. If the hospital s reported median dose is greater than or equal to the Median Benchmark and less than the 75 th Percentile Benchmark, it will receive 1 point. Otherwise, if the hospital s reported median dose is greater than or equal to the 75 th Percentile Benchmark, it will not receive points for that category. Therefore, for each anatomic region, there are at most 10 possible points. If a hospital had less than 10 CT scans for an age stratum, that age stratum is not included in scoring. For each anatomic region, the percentage of points awarded is calculated by summing the points earned and dividing by the total number of possible points (i.e. 2 times the number of age strata with at least 10 CT scans). This percentage of points earned will be used to assign a performance category according to the table below: Pediatric CT Dose Score (Performance Category) Fully Meets the Standard (four-filled bars) Substantial Progress (three-filled bars) Some Progress (two-filled bars) Willing to Report (one-filled bar) Head Scans Abdomen/Pelvis Scans >= 75% of total possible points >= 75% of total possible points >= 50% and < 75% of total possible points >= 50% and < 75% of total possible points >=25% and < 50% of total possible points >=25% and < 50% of total possible points < 25% of total possible points < 25% of total possible points Unable to Calculate Score Fewer than 10 CT scans for all age ranges Fewer than 10 CT scans for all age ranges Does Not Apply Declined to Respond The hospital does not perform CT scans on pediatric patients. The hospital did not measure pediatric scan doses or did not submit a survey. 11

12 APPENDIX I: RESPONSES TO PUBLIC COMMENTS Leapfrog received over 150 public comments in response to the proposed changes to the 2018 Leapfrog Hospital Survey. Comments were submitted from health care organizations, as well as health care experts, patient advocates, and purchasers. Responses to the public comments are organized by survey section below. If you submitted a comment, and do not see a response, or if you have additional questions, please contact the Help Desk at SECTION 1 BASIC HOSPITAL INFORMATION Several commenters expressed agreement with Leapfrog s decision to obtain teaching status from the NHSN Patient Safety Component. Leapfrog is committed to aligning measures and designations with other national organizations as appropriate. Find a complete national crosswalk of 2018 Leapfrog Hospital Survey measures here. Several comments expressed agreement with Leapfrog s decision to update its definition for pediatric admissions to include admission to any inpatient unit (i.e. adult units). This change was in direct response to several hospitals that submitted feedback during the 2017 Survey cycle. We appreciate continued feedback on refining the new definition. Several commenters had questions about which patients to include when reporting on the new pediatric admissions question. The definition of Total Pediatric Acute-Care Admissions has been updated to include acute-care medical and surgical pediatric (aged 17 years or younger) admissions to any inpatient unit. Include transfers from other hospitals as admissions to your hospital. Include any admissions directly to an ICU or NICU (any level NICU) in your hospital, even if counted in question #9. Exclude normal newborn admissions to the nursery and pediatric patients admitted for maternity care, behavioral health, or discharged to hospice. SECTION 2 COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) Some commenters expressed concern regarding the increased CPOE utilization target due to low utilization by nonemployed physician groups. While contracting with external physician groups may present unique challenges in engaging physicians to use CPOE, hospitals first and foremost responsibility is the safety of patients. Leapfrog expects hospital leadership to use maximum leverage to ensure all physicians utilize CPOE for medication ordering. Some commenters felt that requiring physicians to use CPOE to enter all orders reduces the speed and efficiency of care. While entering orders through CPOE can add some time to the ordering process, significant evidence suggests the decision support embedded in CPOE systems provides protection to patients from potentially life-threatening medication errors. Leapfrog s expert panel concluded that these safety benefits outweigh the possible inefficiencies introduced by ordering through CPOE. 12

13 Some commenters expressed concern that some of their physicians refuse to use CPOE due to the perceived steep learning curve. While learning to use CPOE may require a time commitment by physicians, the benefits of CPOE are well established in the literature as important to patient safety. The adoption of CPOE has been shown to significantly reduce the risk of adverse drug events, the most common error made in hospitals. Some commenters noted that community physicians CPOE system interfaces may not sync with the hospital s CPOE interface due to a lack of financial and personnel resources. While aligning community physician CPOE system interfaces with hospital CPOE interfaces may require resources, the added safety that the CPOE provides patients should be a top priority. To the extent this problem threatens patient safety, hospitals should find immediate solutions, possibly to include assisting community physicians with the human and financial resources to help implement the needed interfaces. Some commenters expressed concern over hospitals ability to meet the increased targets for both utilization (change from 75% to 85%) and efficacy (change from 50% to 60%) and suggested we give hospitals additional time to achieve these thresholds. While the higher standards may prove difficult for some hospitals to meet initially, results from previous Leapfrog Hospital Surveys show that most hospitals are already meeting these standards. Leapfrog also believes it is important to continue encouraging hospitals to improve the safety of their care delivery systems. For these reasons, Leapfrog has decided to move forward with the proposed changes of increasing the targets for both utilization and efficacy. Several commenters expressed agreement with the changes to the CPOE Scoring criteria. Based on an analysis of 2017 Leapfrog Hospital Survey Results, almost 50% of hospitals are already meeting the targets of the new, higher criteria. Some commenters requested that the Sample CPOE Test (via the CPOE Evaluation Tool) be expanded to include additional test scenarios. The Sample Test is designed to give hospitals, including the licensed prescriber, an opportunity to practice completing the test process (e.g., time limits and steps, browser compatibility, lab and ADT links, etc.). The Sample Test is an abridged version of the Adult Inpatient Test, and not fully representative of the Test Patients and Test Orders that will appear in the Adult Inpatient Test. It is not meant to predict a hospital s score on the Adult Inpatient Test. Sample Test materials consist of only two Test Patients and four Test Orders. Leapfrog will publish a guidance document developed by the CPOE Evaluation Tool developers to provide hospitals with information on how to improve their clinical decision support capability on the Survey and CPOE Materials webpage on April 1. A commenter asked how the 10 order-checking categories included in the CPOE Evaluation Tool were selected The ten order-checking categories included in the CPOE Evaluation Tool were identified by the CPOE Evaluation Tool developers using several sources: data from the ISMP Medication Error Reporting System, peer reviewed literature, and data from several large health systems including the Veteran s Health Administration, Duke Health, Boston University, and Partners Healthcare. A complete list and description of the order-checking categories is available in Appendix II. Several commenters expressed frustration with their inability to customize their CPOE system s clinical decision support functions and asked if there is a role that the CPOE Evaluation Tool developers can play in communicating safety requirements to the major vendors. The CPOE Evaluation Tool developers have developed a guidance document for hospitals that participate in the CPOE 13

14 Evaluation Tool, which includes information to help hospitals update and improve their clinical decision support system. Hospitals can share this document with their CPOE vendors. Leapfrog will be publishing this document on the Survey and CPOE Materials webpage on April 1. SECTION 3 INPATIENT SURGERY Some hospitals had questions about how Leapfrog s new surgeon volume question would affect surgeons who practice at multiple hospitals. Based on hospital feedback, in lieu of asking hospitals to report on the exact volume for each surgeon, in the 2018 Leapfrog Survey Leapfrog will ask hospitals if they require their surgeons to have minimum experience with a procedure to be privileged at that hospital to perform that procedure. Leapfrog s expert panel has recommended the appropriate minimum level of surgeon volume for each procedure. We expect that hospitals will consider total experience in the privileging process, not just experience gained at a single facility. Some hospitals expressed confusion regarding how to determine which surgeons are privileged at the hospital to perform the eight procedures. Leapfrog recommends checking with surgical leadership at your hospital on the process your hospital uses for privileging surgeons. Every surgeon must have privileges to perform specific procedures. Several commenters noted that they do not support minimum hospital and/or surgeon volume standards as outcomes measures are most important to patients. While Leapfrog recognizes that volume is not a perfect substitute for outcomes, for the eight surgeries being measured in the 2018 Leapfrog Survey, there is a strong body of evidence linking hospital and surgeon experience and patient outcomes. Leapfrog continues to explore opportunities to incorporate evidence-based, endorsed outcome measures (e.g., mortality, morbidity) into the survey. A commenter expressed concern about Leapfrog implementing the surgical volume standards in 2018 because hospitals may not have Leapfrog s minimum volume standards as part of their current privileging process, and putting that in place will take time. As described in Section 3A of this document, hospitals will be able to earn partial credit for committing to include Leapfrog s Minimum Surgeon Volume Standards in their privileging process within the next 12 months. Two commenters noted that procedures may be done by a primary and assisting surgeon, and wanted to ensure the assistant surgeon received credit for the case. For determining surgeon volume, if a surgeon assists another surgeon during a procedure, the procedure should count for both surgeons procedure totals. This would apply when both surgeons are experienced, practicing surgeons. If one or more of the surgeons is a resident, fellow, or being proctored by an experienced surgeon, only the experienced surgeon should receive credit toward her/his procedure total. Surgeons who have just finished their training should receive a 24-month grace period to build up their experience. After that point, his/her volume should be tracked for the surgeon volume. The procedures performed by this surgeon during the reporting period should still be counted towards the hospital s volume total, as the broader staff still had the experience with the surgery. Several commenters noted that the bariatric surgery cases should be limited to those undergoing the procedure for weight loss. Leapfrog found this comment very helpful and has worked to clarify for the 2018 Survey that bariatric surgery needs to be 14

15 done explicitly for weight loss. Hospitals will be given two sets of instructions for identifying these cases: (a) use the listed ICD-10 diagnosis codes to identify those patients who underwent the procedure where obesity was the primary diagnosis or (b) use the listed diagnosis codes to identify those patients who underwent the procedures, where obesity was not the primary diagnosis, but chart review indicated the procedure was performed for the purpose of weight loss. One commenter suggested that Leapfrog give additional credit to hospitals that participate in national clinical registries (i.e. NSQIP) and/or allow hospitals to share their NSQIP outcomes in place of volume. Leapfrog appreciates the importance of registry participation, and continues to work with its surgical expert panel to explore opportunities to add additional outcomes measures into the survey, including clinical outcome measures used in registries. We welcome feedback from hospitals on potential barriers to participating in a national registry. Some commenters questioned why Leapfrog is asking hospitals to develop surgical appropriateness criteria only for these particular eight procedures, even though there may be other procedures with more documented evidence of overuse. Given that Leapfrog is measuring hospital performance based on volume for these eight procedures, Leapfrog seeks to ensure that appropriate safeguards are in place for these eight procedures to ensure there isn t a perverse incentive for hospitals to operate when not necessary. We recognize the importance of overuse as a more widespread problem, and over time, Leapfrog plans to explore additional opportunities to address it. A commenter expressed concern about the burden of implementing appropriateness criteria without sophisticated EHR capabilities. While the implementation of appropriateness criteria can be streamlined and more easily tracked with EHR capabilities, Leapfrog s research and discussions with hospitals have indicated that implementation and monitoring of appropriateness criteria can be achieved without the use of EHR capabilities. Leapfrog has convened an Advisory Workgroup who will be helping to identify resources for hospitals to begin the work of developing, implementing, and monitoring appropriateness criteria. We are planning to host a webinar later this spring. SECTION 4 MATERNITY CARE No comments were submitted. SECTION 5 ICU PHYSICIAN STAFFING Commenters expressed support for Leapfrog s minor update to the scoring algorithm. Leapfrog continues to look for opportunities to clarify the questions and scoring algorithm for Section 5. Additional feedback on the reformatting of the questions in Section 5, as well as the re-formatting of the scoring algorithm are welcomed. SECTION 6 NQF SAFE PRACTICES With regard to Leapfrog s request for feedback on adding unscored questions to Safe Practice 19 Hand Hygiene on the use of electronic hand hygiene monitoring, commenters expressed mixed perspectives. Some commenters noted that electronic monitoring is potentially cost prohibitive for small hospitals while others expressed strong support for electronic monitoring as a best practice. Leapfrog shared the comments with its technical experts and determined that further consultation and fact-finding is 15

16 necessary before adding this to the Survey. Moreover, given the importance of hand hygiene and statistics that point to poor compliance, Leapfrog will convene a national expert panel to review the entirety of Safe Practice 19 Hand Hygiene, including reviewing the latest literature and evidence-based best practices for monitoring compliance with hand hygiene protocols. SECTION 7 MANAGING SERIOUS ERRORS Several commenters expressed concern over Leapfrog s Never Evens Policy Statement that requires hospital to notify an external agency within 10 days. Leapfrog s technical experts have reviewed the comments and recommended that Leapfrog align with the Minnesota Adverse Event Reporting requirements in Therefore, Leapfrog has updated the requirement to report to an external agency on the 2018 Survey from 10 days to 15 business days. Several commenters supported Leapfrog s decision to remove the Hospital-Acquired Pressure Ulcers and Injuries measures from the 2018 Survey, but some commenters noted that these are important safety measures and should not be dropped from the Survey. Leapfrog agrees that measures of hospital-acquired conditions are critical to patients, families, and to healthcare purchasers. However, given the burdens and potential for error reported by hospitals in 2017 in identifying over 3,650 ICD- 10 diagnosis codes for hospital-acquired injuries, Leapfrog must remove these measures for We will continue to include the DRA HAC falls with trauma measure and the PSI 3 Pressure Ulcer Rate in the Hospital Safety Grade. SECTION 8 MEDICATION SAFETY With regard to Bar Code Medication Administration (BCMA), several commenters expressed concern about Leapfrog using the three new process/structural measures to monitor and prevent workarounds in scoring in Leapfrog has reviewed the comments as well as the proposed scoring algorithm for In 2018, hospitals will be able to meet the Leapfrog standard with 6 out of 8 processes or structures in place to prevent workarounds. The updated scoring algorithm is detailed in Appendix IV. With regard to Medication Reconciliation, several commenters expressed concern that the sample sizes are too small, and therefore, not valid. Leapfrog is taking a phased approach to rolling out this measure on the Survey. In 2017, hospitals were asked to sample 10 patients, and responses were not scored or publicly reported. For 2018, hospitals will be asked to sample 15 patients and Leapfrog will publicly report whether or not the hospital has a process in place to protocol in place to collect data on the accuracy of the hospital s medication reconciliation process. We will not score and publicly report a hospital s rate of unintentional medication discrepancies. We will monitor and study the results to determine future reporting and standards for this endorsed measure, which is the only endorsed measure of its kind. With regard to Medication Reconciliation, some commenters questioned why pediatric patients are excluded? The medication reconciliation measure on the Survey is endorsed by the National Quality Forum (NQF 2456: Number of Unintentional Medication Discrepancies per Patient), and unfortunately this measure is currently specified for adult patients only. We will advocate with NQF and measure developers to adapt the measure for pediatric patients. With regard to Medication Reconciliation, some commenters expressed concern that limiting the sampling to patients admitted to medical/surgical units would not result in a representative sample from the hospital and may exclude 16

17 patients with multiple chronic conditions and polypharmacy who are most at risk for medication reconciliation errors. In order to respond to hospital s feedback regarding the challenges of scheduling the interview with the pharmacist and the patient to collect the Gold Standard Medication History, Leapfrog is allowing hospitals to restrict sampling to medical/surgical units in However, hospitals are welcome to sample for additional units if they choose. Sampling from medical/surgical units is the minimum requirement. Two health systems that participated in the national Pilot of the 2018 Leapfrog Hospital Survey noted that they will be monitoring the time spent on data collection for the Medication Reconciliation measure in Any feedback hospitals collect regarding the time commitment to complete data collection would be greatly appreciated. In addition, hospitals may want to refer to the information from the Medication Reconciliation Technical Assistance Calls hosted in 2017 where three different hospitals experienced with the measure shared ways to reduce the time burden of data collection. Materials are posted on the Town Hall Calls webpage. SECTION 9 PEDIATRIC CARE Regarding the CAHPS Child Hospital Survey, several commenters expressed concern with administering the survey for NICU discharges. The Child CAHPS Hospital Survey was designed to be administered to pediatric discharges including NICU discharges. Additional details on fielding the CAHPS Child Hospital Survey can be found here. In 2018, hospitals that have been administering the CAHPS survey without including NICU discharges in their sample can report those results to Leapfrog, provided they meet the minimum sample size and timing requirements in the Leapfrog Hospital Survey. However, we are urging those hospitals to begin including NICU discharges-- per the manual guidelines-- immediately, as CAHPS is designed to include those patients. Hospitals that are just starting to administer the survey in 2018 should include NICU discharges in their sample per the sampling framework detailed in the manual. Regarding the CAHPS Child Hospital Survey, some commenters expressed the cost of administering the survey and low response rates. Some hospitals have asked about the use of alternative, lower cost modes of survey administration, such as administering paper surveys as discharge that can then be batched and mailed to a vendor to calculate results. This approach is potentially an opportunity both lower the cost of administration and increase response rates. Leapfrog s Pediatric Expert Panel, has noted that while administering the CAHPS Child Hospital Survey using paper forms at discharge on the list of AHRQ-approved modes, hospitals that are trying to find ways to administer the survey and increase response rate should be able to submit results to the 2018 Leapfrog Hospital Survey. That said, the Pediatric Expert Panel has expressed a desire for these different modes to be tested, and so we cannot guarantee that you will be able to submit these results for future Leapfrog Hospital Surveys. Regarding Pediatric CT Radiation Dose, several commenters expressed concern that Leapfrog s scoring algorithm for the Pediatric CT Radiation Dose Measures, which gives hospitals credit for having a median average DLP value at or below the 50 th percentile, would drive down doses to ranges that would results in less than optimal scan quality. The measure developer has found in a large randomized trial that routine review and sharing of dosage by hospitals leads to dose reductions without compromise to clinical efficacy. However, Leapfrog has decided to continue requiring hospitals to report on their average 25% DLP and we will carefully monitor the prevalence of low doses. We will work with our national expert panel to make changes to the scoring algorithm as appropriate in the future. 17