The public comment period on the proposed changes to the 2010 Leapfrog Hospital Survey is now closed.   Thank you for your feedback. The Leapfrog Group’s responses to the comments we received during the public comment period have been posted here.

Outlined below are the proposed changes that will be made to the Leapfrog Hospital Survey in 2010.

General Comment

Over the last year, Leapfrog has received feedback from a variety of stakeholders on how quickly the Leapfrog Hospital Survey has evolved. While Leapfrog does take pride in having the Leapfrog Hospital Survey reflect the latest evidence in hospital quality and safety, we do feel it is important to provide purchasers and consumers consistency in the content of the survey, as to more easily compare hospital performance over time.

With that in mind, the 2010 Leapfrog Hospital Survey will primarily be a refresh of the 2009 Leapfrog Hospital Survey. The changes listed below primarily relate to updates to the survey documentation, the removal of survey questions, and tweaks to the scoring algorithms.

After the list of the 2010 changes is a preview of a potential new section of the survey. This new section would be implemented in future survey cycles. Leapfrog would appreciate hearing your comments on this potential new section.


Survey Documentation Update

Historically the Leapfrog Hospital Survey documentation has been organized by the type of information a user would find in the document, rather than by the section of the survey. For a number of years, hospitals responding to the survey have expressed some confusion with how the survey documentation is organized.

Effective with the 2010 Leapfrog Hospital Survey, the survey documentation will be re-organized by the section the survey, directly matching the order of the survey questions.
This includes all of the measure specifications, scoring, frequently asked questions (FAQs), etc. associated with that section of the survey. The survey documentation will now be one large comprehensive file.

For a preview of how the survey documentation will be organized in 2010, please click here.


Computerized Prescriber Order Entry (CPOE) Evaluation Tool

• The Leapfrog CPOE Evaluation Tool is the only publicly available assessment of a hospital’s CPOE implementation. Keeping the CPOE Evaluation Tool current and a valuable experience for hospitals is a top priority of The Leapfrog Group. To accomplish these priorities, some enhancements to the Tool and the testing environment are required. Examples of the potential enhancements include: expanding the Help Desk support (including a telephonic option for communication), creating additional order sets, and expanding the eligibility of hospitals that can access the tool (to include hospitals that have not yet fully implemented their CPOE systems, but are in progress). To implement these enhancements, Leapfrog may need to begin charging hospitals for use of the Tool.

Leapfrog is considering charging hospitals a fee to test their CPOE system with the CPOE Evaluation Tool in the 2010 survey cycle. The fee for conducting a test has not been finalized, as it will depend on the costs of the enhancements listed above, but would likely be in the $5,000 range. The Leapfrog Group would appreciate hearing comments on the proposed enhancements and the possible fee.

• The test orders for the pediatric test in the CPOE Evaluation Tool may be refreshed in the 2010 Leapfrog Hospital Survey, reflecting the latest research in pediatric medication safety.


ICU Physician Staffing (IPS)

• To address the continued shortage of physicians trained in critical care medicine, Leapfrog is considering providing hospitals that are classified as “rural” in the Leapfrog Hospital Survey additional partial credit for having 24 hour/7 day-a-week teleintensivist coverage in all adult and pediatric general medical and surgical ICUs and neuro ICUs.

In addition to having 24 hour/7-day-a-week teleintensivist coverage in each of the applicable ICUs, the partial credit would require care of the patients in these ICUs to be managed or co-managed by the teleintensivist AND an on-site “effector” - physician, physician assistant, nurse practitioner, or a FCCS-certified nurse, -- would need to be physically present in the hospital and be able to reach ICU patients within 5 minutes, 95% of the time, based on a quantified analysis of pager response times.

• As the Leapfrog Hospital Survey has been asking hospitals to report their progress in implementing intensivist staffing in their ICUs for over eight years, and hospitals have had eight years to implement Leapfrog’s standards, Leapfrog’s ICU Physician Staffing expert panel has recommended the removal of the IPS implementation commitment from the survey. The removal of the implementation commitment would have implications on how the IPS Leap is scored.


Evidence-Based Hospital Referral (EBHR) for High-Risk Procedures and Conditions

• The EBHR Expert Panel advised Leapfrog to remove the ‘beta-blocker prescribed at discharge’ process measure for AAA patients (AAA-2).

• The model parameters used in calculating and scoring the Survival Predictors for the six high-risk surgeries –intercepts, coefficients, and national cutpoints – are being assessed by the model developers for appropriateness of use in the 2010 Survey. Any updates to the model parameters would be calculated from the National Inpatient Sample.


NQF Safe Practices Score

• Safe Practices that are measured in the Leapfrog Hospital Survey may be updated to reflect any material wording changes in the 2010 NQF Safe Practices for Better Healthcare Report.

• Responding to user feedback, a small number of the Safe Practice questions may be updated to ensure question clarity.


Common Acute Conditions (CACs)

• In the 2009 Leapfrog Hospital Survey, Leapfrog introduced a series of normal delivery measures. One of the introduced measures was a hospital’s cesarean section rate for low-risk first time births. While the cesarean section measure is NQF-endorsed, hospitals reported difficulty with the collection burden of the measure. In response to the reporting burden concerns, Leapfrog made the decision to remove the measure from the survey mid-cycle. Leapfrog has not yet identified a suitable replacement measure for measuring a hospital’s cesarean section rate. The measure from the 2009 survey will continue to be blanked out in the 2010 survey.

• For hospitals that elect to use a 100 case sample for the Elective Deliveries before 39 weeks measure, an updated sampling start date will be provided in the 2010 survey. This updated sampling start date will help ensure the selected sample can be drawn in time for submission by June 30th.

• The hospital performance target for the Elective Deliveries before 39 weeks measure in 2009 was a rate of 12%. The 12% performance target will remain for the 2010 survey cycle. For the 2011 Leapfrog Hospital Survey, the performance target will be adjusted downwards to 5%, or less, as over 25% of hospitals that reported to the 2009 survey already have achieved this level of performance.


Hospital-Acquired Conditions (HACs)

• After releasing their initial list of ‘no pay’ conditions, the Centers for Medicare and Medicaid Services (CMS) adjusted the ‘no pay’ condition list to reflect just stage III and IV pressure ulcers. New ICD-9 codes were introduced in late 2008 that allowed hospitals to identify the stage of the pressure ulcer, which were unfortunately too late for use in the 2009 Leapfrog Hospital Survey. In the 2010 survey, hospitals will be asked to report only on their rates of hospital-acquired Stage III and IV pressure ulcers. The actual survey questions do not require any modification, but the measure specifications will be updated to reflect the new ICD-9 codes.

• The Leapfrog Hospital Survey asks hospitals to report their rate of central line associated bloodstream infections (CLABSI) in each applicable ICU. A hospital’s performance in each ICU is aggregated together for an overall summary score. In the 2010 Leapfrog Hospital Survey, a standardized infection ratio (SIR) calculation is being considered as the method to use in aggregating a hospital’s performance over the different ICUs. This aggregation methodology would match the methodology recommended by the CDC. CDC/NHSN national averages would be used as the benchmarks for standardization purposes.

• For the 2010 survey, a hospital’s CLABSI rate for an ICU may be suppressed if they report fewer than 1,000 central line days and fewer than five CLABSIs in that ICU. In lieu of a rate, a hospital’s performance would show as “Small sample size”.

• Hospitals that receive an aggregated central line associated bloodstream infection (CLABSI) score of “Willing to Report”, as calculated from their observed CLABSI rates, may possibly earn 1 bar incremental credit on the aggregated score if they participate in their state’s ON THE CUSP: STOP BSI prevention program. The list of states that are currently sponsoring an ON THE CUSP: STOP BSI prevention program can be found at http://www.safercare.net/OTCSBSI/Regions.html.


Never Events Policy

The 60-day commitment period for implementing Leapfrog’s Never Events policy may be removed from the 2010 Leapfrog Hospital Survey. Leapfrog has been asking for three years for hospitals to implement the policy and publicly reporting future commitments is no longer appropriate.


Transparency Indicator

Due to the lack of differentiation in hospital responses, the Transparency Indicator may be removed from the survey. Hospitals could still provide a web link in the demographic section of the survey that consumers and purchasers can use to find out more information about the hospital. Leapfrog urges hospitals to link site visitors to a webpage that displays information on qualify and safety.


POTENTIAL NEW SECTION FOR FUTURE SURVEYS --
Safe Surgical Scheduling

Patients can receive lower quality care as a result of the surgical scheduling practices many hospitals currently employ. Patients can be impacted from a hospital’s less than optimal surgical scheduling practices in the following ways:
• Lack of timely access to emergency care
• Elective surgery delays and/or cancellations to accommodate an emergent surgery
• Boarding of patients in hallways
• Placement in a less preferred unit post-surgery, as there are no beds available in the preferred unit
• Patient census fluctuations, stressing the nursing staff with unmanageable patient loads and providing a greater opportunity for a medical error to occur

Patients should choose a hospital that has taken scientifically identified steps to reduce these types of occurrences. Researchers have identified operations management tools and variability methodology as methods hospitals can successfully use to manage surgical patient demand issues.

Below is a selected list of publications that support the use of operations management and variability methodologies in managing surgical patient flow in hospitals.

• Litvak E, Long MC, Prenney B, Fuda KK, Levtzion-Korach O, McGlinchey P. "Improving Patient Flow and Throughput in California Hospitals Operating Room Services". Boston University Program for Management of Variability in Health Care Delivery. Guidance document prepared for the California Healthcare Foundation (CHCF), 2007

• Litvak E, Buerhaus PI, Davidoff F, Long MC, McManus ML, Berwick DM. “Managing Unnecessary Variability in Patient Demand to Reduce Nursing Stress and Improve Patient Safety.” Joint Commission Journal on Quality and Patient Safety, 2005; 31(6): 330-338.

• Litvak E. "Optimizing Patient Flow by Managing its Variability." In Berman S. (ed.): Front Office to Front Line: Essential Issues for Health Care Leaders. Oakbrook Terrace, IL: Joint Commission Resources, 2005, pp. 91-111.

• McManus ML, Long MC, Cooper AB, Mandell J, Berwick DM, Litvak E. “Variability in Demand and Access to Pediatric Intensive Care Services.” Anesthesiology, 2003(98): 1491-6.


Leapfrog convened an expert panel to determine the appropriate standards hospitals should be held to on managing surgical patient flow and the potential ways hospitals could achieve the standard. This document addresses both the standards identified by the panel for safe surgical scheduling and tips for implementation.

Leapfrog would appreciate hearing comments from all stakeholders on the expert panel’s standards and implementation tips for this potential new section on the survey.