Hospitals within a system must report individually to the Leapfrog Hospital Survey. Each campus within a hospital must submit its own Survey.
It is The Leapfrog Group’s goal to disclose hospital performance information for the benefit of consumers, purchasers, and referring physicians as they make decisions about where to seek care and where to direct patients. Making differences among facilities known to users of healthcare is critical to inform this decision-making. Leapfrog’s policy regarding multi-hospital systems and hospitals with multiple campuses is based on achieving this goal.
Variations in outcomes exist among hospitals within the same healthcare system and among various facilities in a multi-campus hospital. Research demonstrates that for each of Leapfrog’s patient safety standards (computerized physician order entry, ICU Physician Staffing, and Evidence-based Hospital Referrals), large performance variations exist between facilities that have these practices in place and those that do not.
If there is variation among the campuses regarding their progress toward full compliance of the Leapfrog standards, reporting the multiple facilities within a system or multi-campus hospital as one unit potentially undermines consumers’ ability to discern a distinction among the facilities. For example, if a system or multi-campus hospital reports full implementation of intensivist staffing, but only one facility meets the standard, the consumer who wants to receive care at a campus with a full staff of qualified intensivists will not know, of all of the system’s facilities, which one is fully compliant with Leapfrog’s ICU Physician Staffing standard. It is to the advantage of the hospital to disclose separately so patients can make accurate determinations when selecting where to go for their care. If all campuses are equally compliant with the CPOE, ICU Physician Staffing, and NQF Safe Practice standards, the individual facilities simply repeat the answers to the Survey for each discrete hospital or facility. (Please note: Each campus will need to complete its own CPOE Evaluation Tool).
For reporting on high-risk surgeries and conditions, if a hospital system has two or more inpatient units which operate on separate campuses (i.e. are not co-located or physically adjacent), they must be identified as separate hospitals for purposes of the Survey. Even in cases where hospitals’ surgical teams or individual surgeons work at more than one facility in the hospital system or where the multi-hospital healthcare systems have the same quality management policies and procedures, individual facilities must report separately.
Each facility within a system or multi-campus hospital must report on each procedure or condition as performed or treated at its applicable facility. For example, if elective aortic valve replacement (AVR) is performed in one facility only and the neonatal intensive care unit is located in one facility only, each facility should report only on the procedure it performs. If a campus does not perform a specific procedure electively, it should report “no” to those questions and the campus will be scored as “Does Not Apply” for questions related to that procedure.
For those complex procedures performed in multiple facilities within the system or multi-campus hospital, each facility must report separately regarding its adherence to the volume, process, and outcome measure specified by Leapfrog.
Shared Medicare Provider Numbers (MPNs)
Although facilities within a system or multi-campus hospital may be viewed as a single hospital from an operational or administrative perspective (i.e. sharing a Medicare Provider Number, taxpayer ID, hospital license, and medical staff), the individual facilities may have differences when it comes to implementation of Leapfrog’s standards. Therefore, it is our policy that facilities within a multi-hospital healthcare system or facilities within a multi-campus hospital that are not within a contiguous geographic location are considered separate facility campuses and must report separately regardless of common ownership or control.
Unique NHSN IDs
The multi-campus reporting policy also requires that hospitals report separately to NHSN. NHSN’s policy aligns with Leapfrog's and is stated as follows: “If free-standing facilities are located in physically separate buildings, whether on the same property or over multiple campuses, each individual facility should be enrolled separately in NHSN. This applies even if physically separate facilities share a single CMS Certification Number (CCN).” If your facility or system is currently incorrectly enrolled and reporting data from multiple facilities with a single NHSN ID then you will need to follow these NHSN instructions (pg. 9) to address this situation prior to the opening of the 2018 Leapfrog Hospital Survey in April.
Any questions about Leapfrog's reporting policy can be directed to the Help Desk.