The Leapfrog Hospital Survey
What’s New in the 2013 Survey (Version 6.0)
The content changes to the prior year’s survey (2012 v 5.4) are as follows:
1. In Section 1, hospitals will be asked about their membership in The Council of Teaching Hospitals and Health Systems® (COTH®).
2. In Section 3, measures related to both CABG and PCI have been removed from the survey. This is a result of reductions in inpatient mortality since the launch of the Leapfrog Hospital Survey, reductions in the variation in mortality across hospitals, and an increase in the public reporting of outcomes. The removed measures include both quality measures and resource use measures.
In addition, given the absence of a meaningful national outcome measure, Bariatric Surgery has also been removed from the survey until an appropriate outcome measure becomes available.
In the High-Risk Deliveries subsection, hospitals that participate in the Vermont Oxford Network have the opportunity to report their performance on VON’s “Death or Survival with Major Morbidity” measure as alternative to reporting on the volume of very low birth-weight babies (VLBWBs) cared for in the NICU.
3. In Section 4, given the reduced number of nationally endorsed process of care measures that hospitals must report on for the care of heart attack patients and pneumonia patients, these subsections have been removed from the survey. Section 4 has been renamed “Maternity Care.”
In addition to content changes, the following scoring changes will occur in this section as well: (1) a hospital’s rate of early elective deliveries and their episiotomy rate will be scored and reported as independent rates and (2) the two normal delivery-focused process measures will be scored and reported as a single composite score.
4. In Section 7, hospitals are now asked to report their incidence rates of catheter-associated urinary tract infections (CAUTI) in ICUs. A standardized infection ratio will be calculated among patients from all adult and pediatric ICUs.
At the end of the 2010 survey cycle, Leapfrog put two of its hospital-acquired condition measures “in reserve,” as CMS began to publicly report similar data in a meaningful way. In response to CMS’s decision (see update to FY2013 IPPS Rule) to remove incidences of Pressure Ulcers and Injuries/Falls from the Hospital Inpatient Quality Reporting Program, Leapfrog has decided to add these two measure back on to the survey.
In an effort to continue alignment with national reporting standards, the minimum reporting requirements for hospitals reporting their incidence of CLABSIs in ICUs will be aligned with CDC/NHSN. Standardized infection ratios will no longer be calculated and reported for hospitals when the expected number of infections across all ICU types is less than one (1). In lieu of a standardized infection ratio, the hospital will be reported as “Insufficient Sample.”
5. In Section 8, based on hospital feedback, Leapfrog has eliminated the pre- and post-implementation questions. Hospitals will now be asked to use the most recent 6 or 12 month time period to report on their utilization of operating rooms that service inpatients during prime time hours.
6. In Section 9, given space considerations on the Leapfrog Hospital Survey, Leapfrog has decided to remove the three patient experiences of care measures from this section. These measures are currently reported by CMS at www.HospitalCompare.hhs.gov.
7. A new section has been added to highlight how judiciously hospitals use resources to provide care to patients. Hospitals will be reported and scored on their 30-day readmission rates and their risk-adjusted length of stay for three common acute conditions. This section will be named “Resource Use.”
The first composite score will focus on patient readmissions within 30 days for three common conditions (Acute Myocardial Infarction, Heart Failure, and Pneumonia). Hospitals will be asked to report their CMS 30-day risk-adjusted readmission rates for all three conditions and the rates will be combined into a single composite score, with relative weights reflecting the number of discharges of each type. This composite score methodology will mirror the methodology used by Consumer Reports in its hospital rating calculations. (For more information, visit http://www.consumerreports.org/health/resources/pdf/how-we-rate-hospitals/How%20We%20Rate%20Hospitals.pdf).
The second composite score will focus on a hospital’s risk-adjusted length of stay for the same three conditions (AMI, Heart Failure, and Pneumonia), and will utilize the same scoring methodology as the readmissions composite.
8. Survey Deadline: The 2013 Leapfrog Hospital Survey will launch on April 1, 2013. The first reporting deadline will be June 30, 2013. Hospitals that do not complete a survey by June 30th will be reported as “Declined to Respond” when Leapfrog publishes the survey results in July 2013 at www.leapfroggroup.org/cp. The 2013 survey will close on December 31, 2013. This is a change from previous years when the survey was open from April 1st to March 28th of the following year. Hospitals that do not submit a survey by December 31, 2013 will have to wait until the launch of the 2014 survey in April 2014.
Hospitals that do submit a survey by December 31, 2013 will be able to make corrections to their previously submitted sections of the survey until January 31, 2014 when the survey is taken offline. Survey results that are published at www.leapfroggroup.org/cp will be frozen from February 2014 to July 2014.
9. Scoring Changes: The Leapfrog Group will eliminate a score of “response not required” for many sections of the survey. This change will create equity among hospitals across the country that report to Leapfrog, and reflects an evolution to Leapfrog’s hospital roster process and the elimination of targeted versus non-targeted hospitals in Leapfrog’s Regional Roll-Out Areas (see 2013 list at https://leapfroghospitalsurvey.org/get-a-security-code/). Along with this change, scoring differentials for urban and rural hospitals reporting to the CPOE (Section 2) will also be eliminated. If a hospital fails to complete a section of the Leapfrog hospital survey, the score would then result in a score of “Declined to Respond” as all hospitals will be scored equally across the country.
10. Only the hospital’s organizational and contact information from the 2012 survey is retained in the online survey. Review answers in the first section of the survey and update as needed. Hospitals are required to review, update, affirm and submit their survey responses by June 30, 2013. After that date, Leapfrog will no longer report results based on 2012 surveys submitted prior to March 28, 2013.
11. The Leapfrog Group will continue to conduct desk reviews of hospitals’ survey responses in a similar fashion as has been done in previous survey cycles (For more details on the desk review process, please see: (https://leapfroghospitalsurvey.org/about-the-survey/)
In addition to the desk reviews, Leapfrog has asked randomly selected hospitals to provide documentation related to their submitted responses. Given the recent use of the Leapfrog Hospital Survey data by high-visibility data licensees, we do encourage hospitals to be extra careful in ensuring their survey responses are accurate. As a reminder, all quantitative numbers entered in response fields are considered numerical values; there are no opportunities to enter placeholders (0) or codes for missing data (9999) in the Leapfrog Hospital Survey.
12. Hospitals that submit a Leapfrog Hospital Survey by the June 30, 2013 first reporting period deadline will receive a free Leapfrog Hospital Recognition Program (LHRP) Summary Report. LHRP Summary Reports illustrate how your hospital compares to others in the state and the nation in quality, resource use, and efficiency. The reports are generated by applying the LHRP Scoring Methodology to 2013 Leapfrog Hospital Survey responses. The LHRP Summary Reports are mailed to the hospital CEO provided by your hospital in the demographics section of the survey. You can obtain more information about LHRP Reports, the LHRP Scoring Methodology, and more detailed performance reports at www.leapfroggroup.org/lhrpreports.
In some hospital markets, health care payors have licensed the Leapfrog Hospital Recognition Program and offer further recognition and rewards to hospitals that participate in the Leapfrog Survey. To be eligible for recognition or rewards in these hospital markets, hospitals must submit a survey by June 30, 2012 and an updated survey between September 1, 2012 and December 31, 2012. For questions or more information, please contact firstname.lastname@example.org.
13. Any changes made to the measure specifications in the middle of the survey cycle will be reflected in the Leapfrog Hospital Survey Reference Book, under the Change Summary header, for each impacted survey section. In addition, the updates to the specifications will be highlighted in yellow. If the changes are substantial, we will e-mail the survey contact your hospital indicated in the demographic section of the survey. If the notification is sent before your hospital submits a 2013 Leapfrog Hospital Survey, the e-mail will go to the survey contact provided in the last survey submitted in the 2012 survey cycle.
14. The signed affirmation at the end of each section of the survey is used as a check to ensure hospitals are submitting accurate responses to the survey. The affirmation language at the end of each section has been updated to reflect that the affirmation needs to be completed by the hospital CEO or by an employee of the hospital to whom the hospital CEO has delegated responsibility.
Your hospital should also order a copy of the full report of the National Quality Forum’s Safe Practices for Better Healthcare 2010 Update, if you don’t already have one. It is needed to complete section 6 of the survey. See the ordering links on the ‘Download Survey Materials’ page of the online survey for an electronic version of the report.