Hospitals within a system and hospitals with multiple campuses must each submit their own Survey, and responses should be specific to the individual facility.
It is The Leapfrog Group’s goal to publicly report patient safety and quality 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 patients and their families 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.
For the purposes of reporting on the Survey, hospitals that are not in immediate physical proximity to each other (i.e., the two facilities are physically connected, either by a tunnel, an enclosed bridge, or the locations abut each other so that the hallways readily connect) must be identified as separate hospitals. 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.
There is often variation among facilities within the same healthcare system and among facilities in a multi-campus hospital regarding both the services provided and progress toward meeting Leapfrog’s standards. Reporting multiple facilities within a system or multi-campus hospital as a single entity potentially undermines consumers’ ability to discern a distinction among the facilities.
For example, Leapfrog sees significant variation between facilities when reporting standardized infection ratios (SIRs) for the five healthcare associated infections included on the Leapfrog Hospital Survey. In an analysis of 2017 Leapfrog Hospital Survey Results, two hospitals just seven miles apart within one health system on the east coast had CLABSI SIRs of 0.000 (no reported infections) and an alarming 3.755 (meaning the hospital had almost four times the number of infections as would be expected). Consolidated data for these two facilities shows a SIR of 1.775 as reported by the Centers for Medicare and Medicaid Services (CMS) for the same time period. Combining this data obscures important variation among high- and low- performing hospitals.
Shared CMS Certification Number
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 CMS Certification Number, taxpayer ID, hospital license, and medical staff), Leapfrog’s policy requires individual hospitals to submit separate Surveys if they are not in immediate physical proximity to each other as described above.
The multi-campus reporting policy also requires that hospitals report separately to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). NHSN’s policy aligns with Leapfrog's and states the following: “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 the NHSN Guidance document (pg. 8-9) to address this situation.
For questions, please contact the Leapfrog Help Desk.