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What’s New in 2008: The Leapfrog Hospital Survey

April 16, 2008

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Town Hall Call Overview• Introduction

– Survey Team– Leapfrog and the Hospital Survey—why complete?– Goals for 2008 survey

• Survey Submission Logistics/Timeline/Website Resources• What’s New for 2008• Approach to the Survey• Detailed review of survey questions

– Safe Practices Score– Computerized Physician Order Entry (CPOE) – Intensive Care Physician Staffing (IPS)– Evidence-based Hospital Referral (EBHR)– Never Events– Transparency Indicator– Hospital Acquired Conditions– Common Acute Conditions

• Q & A• Schedule for Town Hall Special Calls

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Why Complete Leapfrog Survey?Unique in the Milieu

• Represents employers/purchasers/consumers interests• Seeks public accountability/transparency• Rewards high performance• High impact performance measures “not the low hanging fruit”

(e.g., CPOE, IPS, EBHR, HACs)• Full range of measures—structural, process and outcome (but

focused on outcome)• Regional and national in scope—all payer information • Standardized measures to assure “same fruit” is sampled • Harmonized with other major national performance measurement

programs—but shows more complete picture of care delivery• Significant hospital input for 2008 survey

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Survey Review ProcessSteps in the process to revise the survey have included: 

• (August, 2007) – Roundtable calls - A representative group of hospitals that completed the 2007 Leapfrog Hospital Survey participated in three roundtable calls to share comments and feedback on the 2007 survey.

• (October, 2007) – First review – 14 hospitals reviewed an early draft of the proposed changes to the 2008 Leapfrog Hospital Survey and provided feedback to Leapfrog.

• (November , 2007) - Public review and comment period – hospitals were invited to share comments and feedback on the proposed changes for the 2008 Leapfrog Hospital Survey. 

• (January, 2008) - Pilot test of revised survey – 19 hospitals participated in a test of the draft 2008 Leapfrog Hospital Survey and provided feedback to Leapfrog.

• (February, 2008) - Pilot of CPOE test – Eight hospitals participated in a test of the CPOE evaluation tool and provided feedback to Leapfrog.

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Behind the Changes in 2008

Goals for the new survey—1. Streamline survey—reduce burden2. Reduce ambiguity in language in Safe Practices3. Support CMS initiatives (HACs)4. Align with other performance measurement groups 5. Provide two composites that are important to

consumers and purchasers• Efficiency of care• Survival predictor

6. Incorporate Leapfrog’s Pay for Performance program

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How did we do?

• Significantly reduced survey question pages—now 66 pages vs 106 pages

• Language in Safe Practices tightened to reduce ambiguity/increase action on safety

• Added LHRP conditions and efficiency• Added 2 hospital acquired conditions

identified by CMS• Reduced “LF-developed” measures down to

only a few—hospitals can report their results from other data collections—lowering burden—but providing full picture of care

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Survey Submission Logistics, Timeline, Website Resources

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Submission Issues

• Security Codes and CEO Delegation

• Survey Affirmations and Maintaining survey records of answers

• Helpdesk services

• Website resources

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Survey Security and Integrity

• Core principle: hospital self-certification• Executive authority . . .and accountability• Survey security and integrity are critical:

– 16-digit security code

• Authorization to access granted only to:– CEO . . . can provide code directly to any

delegate(s)– CEO-authorized delegate . . . Help Desk

can email security codes

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Regional Rollout Contacts

• RRO contacts:– Identified on survey home page– Help Desk refers RRO hospitals to contact

for 16-digit code– Hospitals should consider getting CEO

Delegation authorizations for alternative hospital contact person; fax authorizations to the Help Desk

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Survey Helpdesk Available

• Survey Helpdesk—designed to respond within 48 hours of question (unless it requires an expert panel member to respond)

• Don’t wait until June 30—if you have a problem you likely will not make deadline..

• Survey must be completed before CPOE certification. If completing MUST do before last week in June otherwise will not be able to get Help Desk support

• Helpdesk link on survey homepageleapfrog.medstat.com

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2008 Timeline

• April 1, 2008—Leapfrog Launches 2008 Survey

• June 30, 2008- RRO targeted hospitals report or be listed on Leapfrog’s Web site as Did Not Disclose

• July 7, 2008 Website lists new results• Top Hospitals List--Recognition

programs/initiatives will be done in 2008 beginning as early as mid-September

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Website Resources

To assist hospitals in completing the Survey, Leapfrog makes the following tools available: – Frequently Asked Questions– Overview of “What’s New in 2008?” – Fact sheets on Each Leap (including bibliography

information) – White Papers on Severity-adjustment for LOS, and Survival

Predictor– Scoring Algorithms– End Notes– Specifications for measuring and reporting rates of Hospital-

Acquired Conditions – Link to purchase NQF Safe Practices Revised Handbook

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Website Resources for EBHR

• Medical Coding for High-Risk Procedures and ConditionsProcedure code, diagnosis codes and other specifications for counting high-risk surgery volumes

• Publicly Reported Outcomes for CABG and PCIFor hospitals in CA, MA, NJ, NY and PA – publicly reported risk-adjusted mortality rates for responding to survey questions about PCI (MA, NY only) and CABG (all five states).

• Process Measures -- SpecificationsDetailed specifications for Leapfrog’s procedure-specific process measures of quality -- for CABG, PCI, AAA Repair and high-risk deliveries.

• Resource Utilization Measures – SpecificationsDetailed specifications for Leapfrog’s CABG and PCI including:

– Coding for counting eligible cases– Coding and other criteria for identifying cases with risk factors – Specifications for reporting geometric mean length of stay– Criteria for identifying cases followed by readmission

• Excel Tool for Computing Geometric Mean Length of Stay

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Website Resources for Common Acute Conditions (CAC)

• Volume Standard Coding: Medical Coding for Chronic Acute ConditionsProcedure/diagnosis codes and other specifications for counting AMI and Pneumonia volume

• Process Measures - SpecificationsSpecifications for Leapfrog’s nationally-endorsed procedure-specific process measures of quality -- for AMI and Pneumonia.

• Resource Utilization Measures – SpecificationsDetailed specifications for Leapfrog’s Common Acute Conditions (AMI and Pneumonia) – including:

– Coding for counting eligible cases– Coding and other criteria for identifying cases with risk factors – Specifications for reporting geometric mean length of stay– Criteria for identifying cases followed by readmission

• Excel Tool for Computing Geometric Mean Length of Stay

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What’s New for 2008

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Survey Changes: The Details1. Computerized Prescriber Order Entry Evaluation Tool2. Streamlined Safe Practices3. Hospital-Acquired Conditions 4. Common Acute Conditions – AMI & Pneumonia5. Efficiency of Care Score6. Additional Evidence Based Hospital Referral Changes

a. Survival Predictor b. Surgeon Volume Droppedc. Public Reporting Additions- Mass & North. New Engl.d. NICU Volume Changee. Bariatric Volume Standard Increases

7. Expansion of ICU Physician Staffing (IPS) 8. Leapfrog Hospital Rewards Program Changes9. Other Hospital Recommendations

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Computerized Prescriber Order Entry (CPOE) Evaluation Tool

• The CPOE Evaluation Tool provides hospitals an opportunity to assess the hospital’s implementation of system alerts for potential medication-related adverse events

• Test involves a hospital loading computer-generated patient profiles and medication orders into their CPOE system and reporting back on the alerts they received

• Hospitals must complete the test to achieve either Fully Meets or Good Progress on the CPOE Leap in 2008

• In the 2008 survey, scored results will not be used, only the fact that the hospital tested its system. In 2009, scores from the test will be used.

• Hospitals access the tool from the survey website once they have completed the CPOE section of the online survey (i.e. CPOE Q1=YES).

• Same security code as survey.

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CPOE Evaluation – Impact on Overall CPOE Score

• 2008 survey cycle: successful completion of test is the only requirement for credit in CPOE overall score

• 2008 survey scoring algorithm:– Fully implemented:

CPOE implemented, 75%+ IP orders, and appropriate* test completed

– Good progress (3/4):CPOE implemented, <75% IP orders, and appropriate* test completed

– Good early stage effort (1/2):CPOE implemented ORSelecting/implementing, written strategy, budgeted, champion

– Will to report publicly:Completed CPOE section of survey

• 2009: Leapfrog will release results of test, scoring criteria TBD

* Adult inpatient test for adult/general hospital (pediatric test optional); pediatric test for children’s hospital

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CPOE Evaluation – Scored Results, Sample

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CPOE Evaluation – Scored Results, Sample (cont’d)

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Feedback on CPOE Evaluation Tool

“No question—this is a valuable experience—it is very important work and it should be applauded.”

David Stockwell, Patient Safety Officer

Children’s National Medical Center

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Streamlined Safe Practices

• Through numerous hospital roundtable calls, we heard substantial feedback from hospitals on the length and the ambiguity of the 2007 Safe Practices section

• The 2008 Safe Practices chosen for hospitals to report on are those that have the strongest supporting evidence and are not measured in other sections of the survey

• The 2008 Safe Practices section focuses on 13 of the 27 non-Leapfrog-created Safe Practices

• The Safe Practices have kept the 4A framework, but have been re-worded to make the questions more tightly defined and actionable

• Hospitals that wish to continue to report on all 27 Safe Practices may do so through TMIT. Leapfrog will recognize hospitals that do so as part of the survey’s Transparency Indicator section.

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Safe Practices 2008• Basic design of survey ( 4 A’s) remains the

same– Awareness– Accountability– Ability– Action

• Changes to the content– Revisions to existing measures– Individual practice weighting remains the same as

2007, but overall is now 707– Fewer questions—more crisply defined actions

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13 Safe Practices Safe Practice

Weighting (pts)

1 Creating and Sustaining a Culture of Safety Element 1: Leadership Structures and Systems 120 Element 2: Culture Measurement for Performance 20 Element 3: Teamwork Training and Skill Building 40 Element 4: Identification and Mitigation of Risks and Hazards 120

2 Informed Consent 4 3 Life Sustaining Treatment 4 5 Nursing Workforce 100 8 Communication of Critical Information 84 10 Labeling of Diagnostic Studies 15 11 Discharge Systems 25 14 Medication Reconciliation 35 19 Prevention of Aspiration and Ventilator Associated Pneumonia a 20 20 Central Venous Catheter Related Bloodstream Infection Prevention a 30 22 Hand Hygiene 30 28 DVT/VTE Prevention b 25 29 Anticoagulation Therapy b 35

GRAND TOTAL

707

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Hospital-Acquired Conditions

• New section added on two hospital-acquired conditions for which CMS has indicated they will no longer reimburse hospitals

• This survey cycle measures hospital-acquired pressure ulcers and hospital-acquired injuries (burns, falls, etc.)

• Results will be reported as a rate per inpatient days• Pressure ulcers aligned with IHI 5 million lives campaign• These two conditions can be identified by hospitals using the

same codes that CMS is using for its payment reduction • Hospitals will need to rely on CMS-required Present-On-

Admission coding to identify which conditions occurred during the hospital stay.

• Hospitals have until October 31, 2008, to report on six months of data to the survey; after that, results will indicate “Did not measure or report this information”

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Common Acute Conditions

• New section focused on two common acute conditions -- Acute Myocardial Infarction (AMI) and Pneumonia—both were measured in LHRP

• Quality measures for these conditions are based on CMS/Joint Commission Process Measures of Quality

• Scoring thresholds for the quality of care process measures are set based on historical Joint Commission data

• Resource Utilization is measured using severity adjusted LOS inflated by readmission

• Resource Utilization combined with safety and quality measures produce an Efficiency of Care score for these two conditions

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Resource Utilization Measures• Measure: Severity-adjusted average length of stay inflated

by readmission rate• Length of stay associated with resource utilization• Readmission used as inflator to avoid “perverse incentive”

(inappropriately releasing patients too early)• Measurement is specific to a condition--added to

compliment quality measures for four procedures /conditions: CABG, PCI, AMI, and Pneumonia

• For each procedure/condition, hospitals are asked to report:- the average length of stay (logarithmically transformed—GEOMEAN),- the number of cases followed by any readmission to that hospital within 14

days for any cause,- a count of cases with certain risk factors present

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Resource Utilization Reporting

• The clinical information (risk factors) and LOS/Readmission statistics needed to report these data can be accessed from the hospital’s administrative data system; no chart abstraction is necessary]

• Hospital will use an automated worksheet to calculate “GEOMEAN for LOS” (see next slide)

• LF will report the efficiency of care scores as a composite of the two scores and a drilldown of quality and resource utilization scores

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GEOMEAN Calculator

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Evidence Based Hospital Referral (EBHR) Changes

• Additional statewide and regional public risk-adjusted mortality outcomes recognized– Massachusetts for CABG and PCI– Northern New England Cardiovascular Disease Study Group

(NH, ME, and VT) for CABG, PCI, and AVR• NICU census changed to annual count of very-low

birthweight babies; 50+ required to fully meet standard – Based on research by Ciaran Phibbs, Ph.D., and others– All hospitals in the 50+group were over 15 average daily

census—reverse not true—thus, raising the bar!• Reporting time periods specified for those not

participating in a specific reporting program• Resource utilization measures added to CABG and

PCI

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EBHR: Survival Predictor Added• No additional questions from last year• “Survival predictor”—based on volume and non-

adjusted in-hospital deaths--a composite measure that predicts future hospital performance on mortality

• Takes into account number of cases via weights—so that reliability related to small numbers is assured

• No predictor for bariatric surgery in this survey cycle• Developers—Drs. Justin Dimick and John Birkmeyer,

U.Mich Medical School, Doug Staiger from Dartmouth

• Reported as independent score on consumer pages• White paper available on LF website

http://www.leapfroggroup.org/news/leapfrog_news/4729468

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EBHR: Surgeon Volume

• Given addition of the “survival predictor” surgeon volume was dropped—except for bariatric surgeries (no survival predictor available yet)

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Expansion of IPS

• IPS Leap expanded to include neuro ICUs (first specialty ICU included in the standard)

• Patients in a neuro ICU must be managed or co-managed by “neuro-intensivists” or critical care intensivists

• “Neuro-intensivists” are classified as neurologists and neurological surgeons who are board-certified in their primary specialty and who have completed a UCNS-certified fellowship training program in neurocritical care, or a physician who is board certified in neuro-critical care.

• Use of “neuro-intensivists” only applies to neuro ICUs

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Leapfrog’s Hospital Rewards Program Changes

• A revised Leapfrog Hospital Rewards Program™ (LHRP) will be based solely on Leapfrog survey data

• Key data elements of Leapfrog Hospital Insights (LHI) were included in the 2008 survey (LHI database eliminated)

• Any hospital submitting a completed 2008 Leapfrog survey now meets all the reporting requirements for participation in licensed LHRP programs

• A current survey must be submitted by June 30, 2008 to be included in July 2008 LHRP results. An updated 2008 survey must be re-submitted in November/December 2008 to be included in January 2009 LHRP results.

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Other Hospital Recommendations

• Hospitals requested a revamp of the organization of ancillary documents for each section of the survey—this will take place in the 2009 survey

• Revamp of the website—hospitals often had difficulty finding documents—have changed document names to better reflect section of the survey

• Page references to the specific Safe Practices section which the survey question relates to are included in the paper copy of the survey

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Questions?

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Dates of Town Hall Specialty Calls

• Severity adjustment for LOS (resource utilization measure) -- April 25, 2 PM EDT

• CPOE Tool -- May 2, 11 AM EDT

• Survival Predictor -- May 7, 2 PM EDT

Check “News & Events” on Leapfrog’s website for call details and materials