Leapfrog will be hosting a webinar to review these new requirements. For more information please click here.
Beginning in 2017, Leapfrog has removed the burden of data entry for hospitals reporting on any of the five applicable infection measures (Central line-associated blood stream infections (CLABSI) in ICUs and select wards, Catheter-associated urinary tract infections (CAUTI) in ICUs and select wards, Facility-wide inpatient Methicillin-resistant Staphylococcus Aureus (MRSA) Blood Laboratory-identified Events, Facility-wide inpatient Clostridium difficile (C.Diff.) Laboratory-identified Events, and Surgical Site Infections from colon surgery (SSI: Colon)) in Section 7 Managing Serious Errors. Instead, Leapfrog will obtain standardized infection ratios (SIRs) for each of the five applicable infection measures directly from CDC’s National Healthcare Safety Network (NHSN) application. Hospitals are required to join The Leapfrog Group’s NHSN Group in order to be scored and publicly reported on the measures.
Data will be available prior to public reporting on the Hospital Details Page starting on July 12, 2017 for hospitals that:
- Join Leapfrog's NHSN Group by June 22,
- Have a valid NHSN ID provided in the Profile Section of their 2017 Leapfrog Hospital Survey, and
- Have completed, affirmed, and submitted Section 7 of the 2017 Leapfrog Hospital Survey by June 30.
All other data pulls will have NHSN data available on the Hospital Details Page on the same date as public release.
Deadlines and Reporting Periods
|Join by||Leapfrog will download data from NHSN for all current group members||Data downloaded from NHSN will be scored and publicly reported for hospitals that have submitted Section 7 by||Reporting Period||Available on Hospital Details Page|
|June 22, 2017||June 23, 2017||June 30, 2017||01/01/2016 - 12/31/2016||July 12, 2017|
|August 24, 2017||August 25, 2017||August 31, 2017||01/01/2016 - 12/31/2016||September 8, 2017*|
|October 24, 2017||October 25, 2017||October 31, 2017||07/01/2016 - 06/30/2017||November 7, 2017*|
|December 21, 2017||December 22, 2017||December 31, 2017||07/01/2016 - 06/30/2017||January 8, 2018*|
* Same date as public release of survey results
As we have done in previous years, Leapfrog is using two reporting periods for this section of the survey. Prior to September 1, Leapfrog will use the NHSN CMS IQR SIRs for CY2016. Beginning on and after September 1, Leapfrog will use the NHSN CMS IQR SIRs for 2016Q3 to 2017Q2.
Leapfrog will only obtain data from NHSN four times per survey cycle. Hospitals must join Leapfrog’s NHSN Group a day prior to the date that Leapfrog will download the data from NHSN for all current group members. Please carefully review the “Join by” deadlines specified in the table above. Hospitals that fail to meet the “Join by” deadline, will need to wait until the next deadline before their NHSN data is included in their Leapfrog Hospital Survey results. Hospitals that fail to join Leapfrog’s NHSN Group and/or provide a valid NHSN ID in the Profile Section of their 2017 Leapfrog Hospital Survey and/or complete, affirm, and submit Section 7 of their 2017 Leapfrog Hospital Survey will be publicly reported as “Declined to Respond” for all five infection measures.
Leapfrog recommends that hospitals pull their CMS IQR Reports, which are the reports that will be used by Leapfrog, on the same day that Leapfrog will be downloading the data from NHSN for all current group members and save a copy for their own records. Leapfrog uses the data from these reports for publicly reporting your hospital’s performance on the five infection measures. Instructions for outputting these reports are provided in the Reference Information for Section 7B in the hard copy of the 2017 Leapfrog Hospital Survey.
Instructions for Joining Leapfrog's NHSN Group
Note: The following instructions apply to both adult and pediatric hospitals. Both adult and pediatric facilities are required to join Leapfrog's NHSN Group in order to have data reported for Section 7B of their Leapfrog Hospital Survey.
- Log into NHSN (needs to be someone with Administrator rights): https://sams.cdc.gov/
- Select "Group" and then "Join"
- Enter the following:
- Group ID: 44303
- Group Joining Password: LeapfrogHospitalSurvey
- Select "Join Group" button
- After agreeing to the message, you will be brought to the "Confer Rights-Patient Safety" screen where you will see the data Leapfrog is requesting access to.
- You will need to review the requested information and select "Accept" at the bottom of the screen in order to share your data with Leapfrog. Users will be prompted to review and accept the Data Rights Template anytime Leapfrog makes updates to the data they are requesting access to. Failure to accept these changes means that Leapfrog will no longer be able to obtain data for your facility and your facility will be reported as "Declined to Respond" for all five infection measures in Section 7B.
- and indicate that the relevant piece of data is being requested by the Group.
- The ! icon indicates areas of the data rights template that have changed (either a new request or the Group has removed the request).
- The Group will specify criteria for plan status, time period, and event or denominator type for events and denominators.
- The Facility can select the "N/A" box to exclude that item from being shared and can use the drop-downs to include/exclude specific locations.
Important Note: Hospitals must provide an accurate NHSN ID in the Profile Section of their survey and complete, affirm, and submit Section 7 of their 2017 Leapfrog Hospital Survey.
More detailed instructions on joining groups in NHSN and accepting the data requested are available here: http://www.cdc.gov/nhsn/pdfs/groups-startup/joingroup-current.pdf
In alignment with other sections of the survey, Leapfrog requires that hospitals within a system report individually to the Leapfrog Hospital Survey. This policy also applies to hospitals that share a Medicare Provider Number, tax payer ID, hospital license, etc. that are not within a contiguous geographic location. This 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).”1 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 instructions1 to address this situation prior to the opening of the 2017 Leapfrog Hospital Survey in April (by the end of 2017, Quarter 2):
- Continue reporting into one NHSN OrgID for the remainder of the current quarter. For example, if you realize in February 2015 that your healthcare system is incorrectly enrolled, continue reporting this way until all data for 2015 quarter 1 (through March 2015) have been entered.
- Once all data for the current quarter have been entered, continue to use the established NHSN OrgID for the reporting of data from the largest hospital in the healthcare system. You will need to enroll each of the additional hospitals as separate facilities in NHSN. The process of enrolling separate facilities may begin at any time, however we recommend that facilities wait to enter data into the “new” NHSN facilities until the start of the next quarter. To enroll facilities, you will need to have “NHSN Enrollment” listed as an activity on your SAMS profile. Email the NHSN Helpdesk (NHSN@cdc.gov) if you need to have “NHSN Enrollment” added to your SAMS profile.
- Once all data for the current quarter have been entered, inactivate all NHSN locations in the established OrgID that represent units in a physically separate facility. For detailed instructions on inactivating a location, please see page 11 from the 2013 NHSN Newsletter: http://www.cdc.gov/nhsn/PDFs/Newsletters/Newsletter-Dec2013.pdf.
- Complete enrollment and facility set-up for the new NHSN facilities, including proper location mapping. If the facility was using CDA to upload data into NHSN, each new NHSN facility will need a separate OID. The OIDs for the new facilities can be requested using this process: http://www.cdc.gov/nhsn/PDFs/CDA/OID_Assignment_Procedure.pdf. Once the OIDs are obtained, they should be entered into the new NHSN facilities and shared with your vendor.
1Policy and instructions taken from the March 2015 NHSN Newsletter, Volume 10, Issue 1. https://www.cdc.gov/nhsn/pdfs/newsletters/nhsn-nl-march_2015.pdf
FAQs Regarding Joining Leapfrog's NHSN Group
Q: Will the data be shared with other members of the group?
A: No, a facility that joins a group does not have access to any data from other facilities in the group. Data will only be shared with Leapfrog.
Q: How will the data be used?
A: The data will be used to score your facility and provide results for Section 7B Healthcare-Associated Infections in the 2017 Leapfrog Hospital Survey.
Q: What data is being requested?
A: The data being requested by Leapfrog is used to generate standardized infection ratios for CLABSI in ICUs and select wards, CAUTI in ICUs and select wards, Facility-wide inpatient MRSA Blood Laboratory-identified Events, Facility-wide inpatient C.Diff. Laboratory-identified Events, and SSI: Colon within NHSN. Immediately after joining the Group, the facility will be taken to a screen listing the data that the Group is requesting access to, referred to as the "Data Rights Template." A or in the template indicates that a particular piece of data is being requested by the Group. For events and denominators, the facility can indicate "N/A" if an item is not applicable and can use the drop-down boxes on the template to include or exclude non-applicable locations. Other fields on the template are not editable. The facility must select the "Accept" button at the bottom of the screen in order to accept the template of data rights and share data with Leapfrog.
Q: Will Leapfrog be collecting patient identifiers?
A: No, Leapfrog will not be collecting any patient identifiers. When reviewing the Data Rights Template, hospitals will see that we are requesting patient data “without identifiers.”
Q: Who from our facility needs to complete the "join group" process within NHSN?
A: An administrative-level NHSN user is needed to join a Group within NHSN and complete the "Confer Rights" process.
Q: After joining the NHSN Group, what else is required?
A: When a hospital first joins the group they are asked to “confer rights” to the Leapfrog Group, which specifies the data that would be shared with Leapfrog. Leapfrog has set up a Data Rights Template, which specifies the data we are requesting. In addition to joining Leapfrog’s NHSN Group, hospitals must provide a valid NHSN ID in the Profile Section of their Leapfrog survey and complete, affirm, and submit Section 7 of the 2017 Leapfrog Hospital Survey in order to be scored and publicly reported on the infection measures. Once a facility joins and accepts the data sharing and has submitted the necessary items in their survey, there is nothing else that is required. If Leapfrog updates the data rights we are requesting, then the NHSN administrator would be notified when they next log into NHSN. They have the option to accept the updated data sharing request or leave the group. Hospitals will be able to view the data that is being pulled into their Leapfrog Hospital Survey results by accessing their Hospital Details Page on the dates listed in the "Deadlines and Reporting Periods" table featured above.
Q: Will Leapfrog notify hospitals if the Data Rights Template is updated and they need to re-accept it within NHSN?
A: Yes, Leapfrog will e-mail the NHSN administrator of each facility that is a member of our NHSN group if we update the data we are requesting access to. Hospitals will be prompted to review the updated Data Rights Template and re-accept it when they next log into NHSN. Failure to do so will result in leaving Leapfrog’s NHSN Group and Leapfrog will no longer be able to obtain NHSN data for your facility on these five infection measures. You will be reported as “Declined to Respond” for all five infection measures in Section 7B Healthcare-Associated Infections.
Q: How often is Leapfrog updating the data? Won't regular updating cause changes to the data?
A: Leapfrog will obtain data from NHSN four times per survey cycle. This allows Leapfrog to obtain data for new hospitals that may not join the NHSN Group by the first deadline and to use the most current data. The reporting period (CY 2016) will remain the same until September 1, when we will start pulling data using the updated reporting period (2016 Q3 – 2017 Q2). Within a reporting period, a hospital’s data would only change if they update the surveillance data submitted for that reporting period within NHSN. This should be rare as there is at least a 6 month reporting lag.
Q: When will the Hospital Details Page be published and how often will it be refreshed?
A: Data will be available prior to public reporting on the Hospital Details Page starting on July 12, 2017 for hospitals that:
- Join Leapfrog's NHSN Group by June 22,
- Have a valid NHSN ID provided in the Profile Section of their 2017 Leapfrog Hospital Survey,
- Have completed, affirmed, and submitted Section 7 of the 2017 Leapfrog Hospital Survey by June 30.
This allows hospitals to preview results before they are reported publicly on July 25. All other data pulls will have NHSN data available on the Hospital Details Page on the same date as public release. For all deadlines and release dates, please see the “Deadlines and Reporting Periods” table featured above.
Q: Will joining the Leapfrog NHSN Group prohibit us from joining other NHSN Groups?
A: No, facilities may join multiple groups within NHSN.
Q: How will older data be handled for facilities that need to go through the process of separating out their multi-campus hospitals and getting new OrgIDs within NHSN?
For instance, if a pediatric facility has been reporting with their adult hospital and now needs to be set up with its own OrgID in NHSN, will the facility need to back-fill in the data from 2016 or will there not be any data available for that time period?
A: Hospitals should follow the instructions provided above for multi-campus reporting (also in NHSN’s March 2015 newsletter) to enroll their new facilities in NHSN and start reporting separately at the start of a new quarter. There should be no need to fill in any historical data and doing so would create problems with risk-adjustment and in verifying CMS data. Hospitals with new OrgIDs will likely not have enough data and will be reported as “Unable to Calculate Score” for the 2017 Leapfrog Hospital Survey. It’s important that hospitals start the process of separating their campuses out at the start of a new quarter and as soon as possible.
Q: Why might there be discrepancies between what a hospital pulls from NHSN for the CMS IQR reports and what is shown on CMS Hospital Compare for the same reporting period?
A: There can be differences for a variety of reasons:
- Hospital shares a Medicare Provider Number and their data is aggregated before it is sent to CMS and displayed on Hospital Compare.
- Hospital Compare is currently using new baselines and risk adjustments, which require running a new report in NHSN. Please be sure you have obtained the correct report by following the instructions provided in the Reference Information for Section 7B in the hard copy of the survey.
- Hospital Compare data is frozen based on the quarterly reporting deadline, whereas NHSN is constantly changing if a hospital changes their data. NHSN encourages hospitals to save their CMS IQR reports from NHSN at the end of each reporting period.
Q: Who should hospitals contact if they have other questions?