here - The Leapfrog Group

Report
What’s New in 2014:
The Leapfrog Hospital Survey
Town Hall Calls
May 13, 2014 and May 28, 2014
1
Town Hall Call Overview
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Introduction
– Goals for 2014 survey
Survey Submission
– Online survey and logistics
– Website resources
– Timeline
What’s New for 2014
– Online Survey Tool – Quick Start Guide
– Section 2: CPOE Evaluation Tool
– Section 3: Evidence-based Hospital Referral (EBHR)
– Section 4: Maternity Care
– Section 5: ICU Physician Staffing (IPS)
– Section 6: NQF Safe Practices
– Section 7: Hospital Acquired Conditions (HACs)
– Section 8: Safety Focused Scheduling
– Section 9: Resource Use for Common Acute Conditions
How Results are Displayed and Used by Others
Q&A
2
Survey Review Process
Steps in the process to revise the survey have included:
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(August/September 2013) Staff and expert panelist set goals, review
latest measures, review changes to endorsement status, consider
member and hospital recommendations from the previous year
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(November, 2013) Publish proposed changes for public comment
period – hospitals and other stakeholders invited to share comments
and feedback on the proposed changes for the 2014 survey
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(January, 2014) Pilot test of revised survey where hospitals are asked
to test a draft of the 2014 survey and provide feedback
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Behind the Changes
Goals for the survey—
1.
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3.
4.
5.
6.
7.
8.
Expand survey to more hospitals
Keep reporting burden as low as possible
Continue alignment with other performance measurement
groups (such as CDC-NHSN; CMS; The Joint Commission)
Include cutting-edge measures that improve the safety,
quality, and efficiency of care delivery
Maintain consistent measurement structure for LHRP and for
improvement purposes
Update measures with guideline changes
Add new performance measurement entities
Maintain measures meaningful to purchasers and consumers
4
How did we do?
• Bulk of survey remains identical to the 2013 survey, including
the performance cut-points for several measures
• Added two measures, but neither will be publicly reported in
2014: NTSV Cesarean Section and OR Access
• Added some exploratory questions at the end of Section 6
regarding culture of safety surveys.
• Removed AAA process measure
• Updated measure specifications to maintain alignment with
other measurement entities (CMS, The Joint Commission)
5
Survey Submission Logistics, Website
Resources, and Timeline
6
Survey Security and Integrity
• Core principle: hospital self-certification via affirmation
• Executive authority and accountability
• Survey security and integrity are critical:
– 16-digit security code
• Authorization to access granted only to:
– CEO . . . can provide code directly to any delegate(s)
– CEO-authorized delegate . . . Help Desk can email security
codes. See survey website, “Get a Security Code”
7
Website Resources
Survey home page at www.leapfroghospitalsurvey.org includes links to:
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2014 Quick Start Guide
Request a security code
Hardcopy of the survey
Leapfrog Hospital Survey Reference Book
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Measure specifications
Frequently Asked Questions
Scoring Algorithms
Changes since initial release 4/1/2014
Other links on home page
– “What’s New in 2014”
– Survey deadlines
– Excel tool for computing Geometric Mean Length of Stay, SIR, and
Adjusted C-section Rate
– Supplemental info re: Resource Utilization scoring and Survival Predictors
– Fact sheets
– White Papers on Severity-adjustment for LOS and Survival Predictor
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Download Survey Materials
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Survey Dashboard
Only appears once you have
submitted a survey. Always
print a copy of your last
submitted survey and review it
for accuracy and
completeness.
Only appears once you have
saved a survey. Remember,
saved survey responses are
not scored.
NEW THIS YEAR!
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Survey Dashboard
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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.
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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.
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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.
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PRINT LAST SAVED SURVEY – Generates a PDF document that includes any responses that have been
entered and saved.
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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.
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PRINT LAST SUBMITTED 2013 SURVEY – Generates a PDF document that includes responses from your Last
Submitted 2013 Leapfrog Hospital Survey.
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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.
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Survey Legend
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Survey Helpdesk Available
• Survey Help Desk -- responds within 24-48 hours
(unless expert panel advise is needed)
• Link on survey homepage
leapfroghospitalsurvey.zendesk.com
• Tips:
– Section 2 of the survey must be submitted before CPOE
Evaluation Tool is taken.
– Don’t wait. Leapfrog’s deadlines are firm.
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2014 Important Dates
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April 1st – 2014 survey opens
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June 30th – first reporting deadline – hospitals that do not submit a survey
by this date will be reported as “Declined to Respond”
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July 25th - Leapfrog website lists new results (www.leapfroggroup.org/cp)
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August 31st –
– Hospital Safety Score data snapshot date
– Top Hospitals
– LHRP
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December 31st – deadline for the 2014 survey (no new surveys or
CPOE tests can be submitted after this date)
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January 31st – end of correction period; 2014 survey closes
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Feb – July – 2014 results frozen on leapfroggroup.org/cp
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What’s New for 2014
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Section 2:
Computerized Prescriber Order Entry
Change:
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).
Reasoning:
Hospitals have requested additional time to enter orders into their CPOE System.
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/cpoeevaluation-tool/.
Impact:
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/cpoeevaluation-tool/.
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Section 3:
Evidence Based Hospital Referral (EBHR)
Change:
Removed AAA Process Measures (SCIP-Card 2) from Section 3B.
Reasoning:
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.
Impact:
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 have
been scored on the Pancreatectomy and Esophogectomy subsections of the survey.
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Section 3:
Evidence Based Hospital Referral (EBHR)
Change:
Replaced Leapfrog’s Antenatal Steroids Measure with The Joint Commissions PC-03
Antenatal Steroids Measure.
Rationale:
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. With changes to The Joint Commissions mandatory reporting requirements,
Leapfrog has decided to replace the second option (Leapfrog’s own measure
specifications) with the Joint Commission’s PC-03 Antenatal Steroids measure.
Impact:
Hospitals will continue to have the option of reporting data submitted to the Vermont
Oxford Network. 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.
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Section 4:
Maternity Care
Change:
Addition of NTSV Cesarean Section Measure.
Rationale:
The NTSV cesarean section delivery measure focuses attention on a population of women
who are low-risk and delivering for the first time. Unlike other cesarean section delivery
measures, the NTSV cesarean section delivery rate is associated with concrete quality
improvement activities that can be performed to address the differences in cesarean
delivery rates among hospitals. These quality improvement activities include reducing
admissions in early labor and eliminating elective labor induction before 41 weeks in the first
births.
Impact:
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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Section 5:
ICU Physician Staffing
Change:
Hospitals have the 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 onsite in these units and provide clinical care exclusively in one ICU during these hours.
Rationale:
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.
Impact:
Hospitals have greater flexibility in staffing structure to earn a score of “substantial progress” on
the IPS standard. Please see page 48 of the survey reference book for detailed information on the
IPS scoring algorithm.
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Section 6:
NQF Safe Practices
Change:
At the end the Safe Practices section, hospitals are asked to provide information about the
culture of safety instrument they are using
Rationale:
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.
Impact:
Information that will be used to inform future survey questions. Responses to these extra
questions will not be scored or publicly reported.
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Section 8 :
Safety Focused Scheduling – OR Access
Change:
Added 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.
Reasoning:
The goal of these new questions is to ensure that hospitals are achieving appropriate
utilization rates without sacrificing patient access.
Impact:
These results will not be publicly reported 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 OR Access section on the
Leapfrog Hospital Survey Results website.
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Section 8 :
OR Access Scoring Algorithm
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Fully meets the standard (4 filled bars): The hospital can document at least 75% of surgical subspecialties
met their access targets 80% of the time for unscheduled cases, stratified by urgency level.
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Substantial Progress (3 filled bars): The hospital can document at least 50% of surgical subspecialties met
their access targets 80% of the time for unscheduled cases, stratified by urgency level.
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Some Progress (2 filled bars): The hospital can document at least 25% of surgical subspecialties met their
access targets 80% of the time for unscheduled cases, stratified by urgency level.
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Willing to Report (1 filled bar): The hospital can document less than 25% of surgical subspecialties met their
access targets 80% of the time for unscheduled cases, stratified by urgency level.
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Does Not Apply: Hospitals that do not operate more than one operating room that services inpatients
(Answered “No” to Smooth Patient Scheduling question #1).
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Response Not Required: Hospital reported that elective surgeries made up less than 10% of their total
admissions (Answered “No” to Smooth Patient Scheduling question #2) and choose not to provide responses
for the remaining questions.
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Declined to Respond: The hospital did not provide responses to this section OR answered ‘no’ to question
#1 in this subsection OR answered ‘Choose Not to Report’ or ‘Can Not Measure’ to question #2 in this
subsection.
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Section 9:
Resource Utilization for Common Acute Conditions
Change:
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.”
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Ensuring Data Integrity
• Leapfrog will continue to conduct reviews of hospital responses
(find details at https://leapfroghospitalsurvey.org/web/wpcontent/uploads/deskreview.pdf)
• Leapfrog continues to add high-visibility data licensees and
release high-profile press campaigns (i.e. early elective
deliveries)
• 2013 – Leapfrog had a random 1% of responding hospitals
submit documentation for specific responses to provide greater
assurance of data accuracy (e.g., hospitals asked to provide a
copy of their Never Events policy and to document safe practice
adherence)
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How Results are Displayed and Used
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How Results Are Displayed
www.LeapfrogGroup.org/cp
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How Results are Used
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Updated monthly (within the first 5 business days of the month) from July through
February to reflect updates and new survey submissions
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Viewed by Leapfrog members and partners, as well as other employers, purchasers,
and consumers
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Used to recognize high performance by Leapfrog, our members and Regional RollOuts, and by health plans (e.g. Top Hospitals and LHRP)
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Used by other statewide and national organizations, regional and national health
plans, and publicly reported by other transparency vendors
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Used to calculate the Hospital Safety Score (www.HospitalSafetyScore.org)
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Used as a quality improvement tool and a benchmarking tool by hospitals
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Questions?
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