Survey and CPOE Materials

2023 Leapfrog Hospital Survey (PDF) (version 2, Updated July 21, 2023)

 

2023 Leapfrog Hospital Survey (Word) (version 2, Updated July 21, 2023)

 

Download the Summary of Changes to the 2023 Leapfrog Hospital Survey here.

The hard copy of the Survey contains important information that you will need to accurately respond to the Survey questions and can be used to collect the information you will need to complete the Online Hospital Survey Tool. The questions in the hard copy of the Survey match the Online Hospital Survey Tool exactly, so responses can be recorded on the hard copy of the Survey and then entered into the Online Hospital Survey Tool. The hard copy of the Survey includes:

• Survey Questions and Endnotes
• Reporting Periods
• Measure Specifications
• Frequently Asked Questions 

Any changes to the 2023 Leapfrog Hospital Survey that are published after April 1 will be listed here:

June 13, 2023

• Section 4D Episiotomy and Section 4E Process Measures of Quality: Added APR-DRG and Tricare DRG codes used to identify vaginal deliveries and cesarean deliveries for reporting on Episiotomy in Section 4D and DVT Prophylaxis in Section 4E. Please review the updated measure specifications on pages 163 and 165 of the Survey.

• Section 5 ICU Physician Staffing: Updated endnote #36 Certified in Critical Care Medicine to reflect updated pathway to certification offered by ABNS for neurointensivists. Please review updated endnote #36 on pages 311-312 of the Survey.

• Section 9C Volume of Procedures: Added 14 adult and 18 pediatric CPT Codes used to identify Other Hernia Repairs and added one adult and one pediatric CPT Code used to identify Nasal/Sinus Procedures that were previously noted as removed. Updates are reflected in the Outpatient Procedure CPT Code workbook for Other Hernia Repair in the Adult and Pediatric General Surgery tab and for Nasal/Sinus Procedure in the Otolaryngology tab.

  Please download an updated copy of the Outpatient Procedure CPT Code workbook from the Survey Dashboard. Instructions for downloading the workbook are available on page 285 of the Survey.

July 21, 2023

• Section 6C Nursing Workforce Total Nursing Care Hours per Patient Day, RN Hours per Patient Day, and Nursing Skill Mix: Updated exclusions for medical, surgical or med-surg units with fewer than 15 patient days per month for all three months during a quarter and units that were closed for an entire quarter of the reporting period. Please review updated specifications on page 202 of the Survey.

 

Other Supporting Materials

The following documents provide critical information that you will need to complete the Leapfrog Hospital Survey. Please review each document carefully before you begin.

Section	Materials
Section 1: Basic Hospital Information	Section 1C: Informed Consent AHRQ Training Module CMS Toolkit for Making Written Material Clear
Section 2: Medication Safety	Section 2A: Computerized Physician Order Entry (CPOE) CPOE Tool Instructions CPOE Tool Instructions File Entity theme CPOE Tool Guidance CPOE Tool Guidance File Entity theme   Section 2D: Medication Reconciliation Medication Reconciliation Workbook Medication Reconciliation Workbook File Entity theme Medication Reconciliation Worksheet Medication Reconciliation Worksheet File Entity theme Best Possible Medication History: Quick Tips Best Possible Medication History: Quick Tips File Entity theme Identifying Discrepancies Flow Chart Identifying Discrepancies Flow Chart File Entity theme   Medication Reconciliation Implementation Toolkit (free) The MARQUIS Collaborative (fee) Taking a Good Medication History Video
Section 3: Adult and Pediatric Complex Surgery	Sections 3A: Hospital and Surgeon Volume Complex Surgery ICD 10 Codes Complex Surgery ICD 10 Codes File Entity theme CPT Code Workbook available via Online Survey Tool   Section 3C: Safe Surgery Checklist for Adult and Pediatric Complex Procedures  Safe Surgery Checklist Workbook WHO Implementation Manual WHO Implementation Manual File Entity theme
Section 4: Maternity Care	Sections 4A-4E CMQCC Instructions   Section 4F: High-Risk Deliveries  VON Data Sharing Authorization VON Nightingale Instructions VON Nightingale Instructions File Entity theme
Section 6: Patient Safety Practices	Sections 6A-6B NQF Safe Practices for Better Healthcare 2010 NQF Safe Practices for Better Healthcare 2010 File Entity theme   Section 6B: NQF Safe Practice #2 – Culture Measurement, Feedback, and Intervention Guidelines for a Culture of Safety Survey Guidelines for a Culture of Safety Survey File Entity theme
Section 7: Managing Serious Errors	Section 7A: Never Events CANDOR Toolkit ​ RCA2 Improving Root Cause Analyses and Actions to Prevent Harm RCA2 Interviewing Tips RCA2 Interviewing Tips File Entity theme   PACT Driver Diagram PACT Process Map PACT Communication Tip Sheet PACT Patient & Family Pathway   Section 7B: Healthcare-Associated Infections  Instructions and FAQs for Joining Leapfrog's NHSN Group
Section 8: Pediatric Care	Section 8B: Pediatric Computed Tomography (CT) Radiation Dose CT Dose Workbook CT Dose Workbook File Entity theme
Section 9: Outpatient Procedures	Section 9C: Volume of Procedures CPT Code Workbook available via Online Survey Tool   Section 9D: Safe Surgery Checklist for Adult and Pediatric Outpatient Procedures  Safe Surgery Checklist Workbook WHO Implementation Manual WHO Implementation Manual File Entity theme   Section 9E: Medication Safety Medication Safety Workbook

 

Leapfrog Hospital Survey Binder

The Leapfrog Hospital Survey Binder document is available for use by all hospitals to collect, organize, and record information during the completion of the Leapfrog Hospital Survey. The document can be printed and placed in a binder. The information is helpful when completing subsequent years' Surveys, in staff and leadership transitions, and as a historical record. The use of the binder also acquaints hospitals with the elements of Leapfrog’s verification protocols.