overview of the fall 2016 hospital safety score · new branding as of fall 2016, the hospital...

OVERVIEW OF THE FALL 2016 HOSPITAL SAFETY SCOREMissy Danforth

Vice President, Hospital Ratings, The Leapfrog GroupSeptember 21, 2016

Presentation Overview2

Program Name and Branding Updates General Info & Eligibility Measure Highlights Reporting Periods Methodology Details of the Courtesy Safety Grade Review Period Important Dates Proposed Changes to 2017 Leapfrog Hospital Safety

Grade Questions

NAME AND BRANDING UPDATES3

New Branding

As of Fall 2016, the Hospital Safety Score will be re-branded as the Leapfrog Hospital Safety Grade

Intent is to reduce confusion for consumers and purchasers, and emphasize that this is one of many of The Leapfrog Group’s programs/offerings

www.HospitalSafetyGrade.org (live when new branding launches with release of letter grades at the end of October)

4

ABOUT THE SAFETY GRADE5

What is the Leapfrog Hospital Safety Grade?

6

The Leapfrog Hospital Safety Grade is an A, B, C, D, or F letter grade reflecting how safe hospitals are for patients.

The Leapfrog Hospital Safety Grade launched in June 2012 and was formerly known as the Hospital Safety Score. The grade is issued two times per year: April and October. This fall will be the tenth release.

More information is available at www.HospitalSafetyScore.org

What Hospitals Will Receive a Leapfrog Hospital Safety Grade?

7

General, acute-care hospitals for which there is adequate public data

The following hospitals are excluded: Specialty hospitals (i.e., surgical centers, cancer hospitals,

women’s hospitals, etc.) Critical Access Hospitals Free-standing Pediatric facilities Non-IPPS participating hospitals (hospitals from the state of MD) Hospitals Missing Too Much Data:

More than 9 process measures; or, More than 5 outcome measures

SCORING OVERVIEW8

Measure Selection Criteria9

Measures are publicly-reported from national data sources, reflecting individual hospital results Leapfrog Hospital Survey

Centers for Medicare & Medicaid Services data sets

American Hospital Association’s Annual Survey and HIT Supplement

Measures are endorsed or in use by a national measurement entity

Measures are linked to patient safety (“freedom from harm”) Directly quantifying patient safety events

Assessing processes that lead to better outcomes

Identified by experts as important to patient safety

Process and Structural Measures10 Measure Name Primary Data Source Secondary Data Source

Process and Structural Measures (15)

Computerized Physician Order Entry (CPOE) 2016 Leapfrog Hospital Survey 2015 HIT Supplement ii

ICU Physician Staffing (IPS) 2016 Leapfrog Hospital Survey 2014 AHA Annual Survey i

Safe Practice 1: Leadership Structures and Systems 2016 Leapfrog Hospital Survey N/A

Safe Practice 2: Culture Measurement, Feedback & Intervention 2016 Leapfrog Hospital Survey N/A

Safe Practice 3: Teamwork Training and Skill Building 2016 Leapfrog Hospital Survey N/A

Safe Practice 4: Identification and Mitigation of Risks and Hazards 2016 Leapfrog Hospital Survey N/A

Safe Practice 9: Nursing Workforce 2016 Leapfrog Hospital Survey N/A

Safe Practice 17: Medication Reconciliation 2016 Leapfrog Hospital Survey N/A

Safe Practice 19: Hand Hygiene 2016 Leapfrog Hospital Survey N/A

Safe Practice 23: Care of the Ventilated Patient 2016 Leapfrog Hospital Survey N/A

H-COMP-1: Nurse Communication CMS N/A

H-COMP-2:Doctor Communication CMS N/A

H-COMP-3: Staff Responsiveness CMS N/A

H-COMP-5: Communication about Medicines CMS N/A

H-COMP-6: Discharge Information CMS N/A

i AHA Annual Survey, Health Forum, LLC, a subsidiary of the American Hospital Associationii AHA Annual Survey © 2014 Health Forum, LLC

Outcome Measures11 Measure Name Primary Data Source Secondary Data Source

Outcome Measures (15)

Foreign Object Retained CMS N/A

Air Embolism CMS N/A

Falls and Trauma CMS N/A

CLABSI 2016 Leapfrog Hospital Survey CMS

CAUTI 2016 Leapfrog Hospital Survey CMS

SSI: Colon 2016 Leapfrog Hospital Survey CMS

MRSA 2016 Leapfrog Hospital Survey CMS

C. Diff. 2016 Leapfrog Hospital Survey CMS

PSI 3: Pressure Ulcer CMS N/A

PSI 4: Death Among Surgical Inpatients CMS N/A

PSI 6: Iatrogenic Pneumothorax CMS N/A

PSI 11: Postoperative Respiratory Failure CMS N/A

PSI 12: Postoperative PE/DVT CMS N/A

PSI 14: Postoperative Wound Dehiscence CMS N/A

PSI 15: Accidental Puncture or Laceration CMS N/A

Change in Fall 2016

Measure Highlights12

29 of the 30 measures have fully updated data since Spring 2016 (both primary and secondary data sources) Leapfrog Hospital Survey Results for CPOE, ICU Physician Staffing, NQF Safe Practices, CLABSI, CAUTI,

SSI: Colon, MRSA, and C. diff

All CMS measures (HCAHPS, HACs, HAIs, PSIs)

AHA HIT Supplement for CPOE

The AHA Annual Survey is the only data source that hasn’t been updated – it is used as a secondary data source for ICU Physician Staffing

For Fall 2016, the 2016 Leapfrog Hospital Survey will become the primary data source for the following measures: SSI: Colon

MRSA

C. diff

CLABSI & CAUTI Data CMS data will no longer be used for hospitals that receive “Unable to Calculate Score” for

CLABSI/CAUTI on the Leapfrog Hospital Survey

Reporting Periods13

Leapfrog Hospital Survey Measures The 2016 Leapfrog Hospital Survey includes two reporting periods:

Hospitals that submit a survey before September 1, 2016 are asked to report on the 12-months ending December 31, 2015.

Hospitals that submit a survey on or after September 1, 2016 are asked to report on the 12-months ending June 30, 2016.

Because the data snapshot date is August 31st, the reporting period for the Leapfrog Hospital Survey will be listed as 01/01/2015 -12/31/2015 for all Leapfrog Hospital Survey measures.

CMS Measures A list of reporting periods for CMS measures is available online at

https://www.medicare.gov/hospitalcompare/Data/Data-Updated.html

Weighting Process14

Two measure domains, each weighted 50%: Process/structural measures Outcome measures

Three criteria for weighting individual measures: Strength of evidence (rating of 1 or 2) Opportunity (rating of 1, 2, 3), based on coefficient of variation Impact (rating of 1, 2, 3) based on:

number of patients possibly affected by the event (0, 1, 2, 3) severity of harm to individual patients (1, 2, 3)

Weight Score = [Evidence + (Opportunity x Impact)

Z-Score Methodology15

Standardizes data from individual measures with different scales

Counts how many standard deviations a hospital’s score on the measure is away from the mean

Mean is set to 0 Negative z-score: worse than the mean

Positive z-score: better than the mean

How to Calculate Z-Score from Raw Measure Score: Process/structural measures:

(Raw Measure Score – Mean)/Standard Deviation

Outcome Measures: (Mean – Raw Measure Score)/Standard Deviation

Overall Numerical Score16

Summation of z-score for each measure multiplied by the weight for each measure

If measure has missing data, then the weight for that measure is re-apportioned to other measures within the same domain

3.0 is added to each hospital’s final numerical score to avoid possible confusion with interpreting negative patient safety scores

3.0 + CPOE z-score × CPOE weight + IPS z-score x IPS weight + CLABSI z-score × CLABSI weight . . . . etc.

DETAILS OF THE COURTESY SAFETY GRADE REVIEW

17

Secure Website

http://www.HospitalSafetyScore.org/data-review18

Contact Information19

Source Data20

Where to Locate Source Data –Leapfrog Hospital Survey

21

Leapfrog Performance Category

Displayed on Leapfrog’s Public Reporting Website

http://www.leapfroggroup.org/compare-hospitals

Measure Score for Hospital Safety Score

Calculation

“Fully meets standard” 4 filled-bars 100

“Substantial progress” 3 filled-bars 50

“Some progress” 2 filled-bars 15

“Willing to report” 1 filled-bar 5

“Declined to respond”

See ‘Uses of Secondary Data’

Table provided in Data Review Instructions

Where to Locate Source Data - CMS22

Enter MPN without the Dash in Search Box

Where to Locate Source Data – AHA23

AHA Data is used for hospitals that didn’t submit a 2016 Leapfrog Hospital Survey by August 31, 2016.

2014 AHA Annual Survey Secondary data source for ICU Physician Staffing

2015 HIT Supplement to the 2014 AHA Annual Survey Secondary data source for CPOE

Please contact the AHA Health Forum for more information

What if the Measure Score Doesn’t Match the Public Report?

24

Hospitals are asked to contact the help desk immediately once they have confirmed the data source, measure, and reporting period.

Hospitals must provide a copy of the public report that shows the different score.

If we find a recording error, we will update the score and re-issue a numerical score and safety grade.

Preview Numerical Score25

Important Dates26

August 31st – Data Snapshot Date For hospitals that have submitted a Leapfrog Hospital Survey by August 31, 2016 –

TBA – E-mail will be sent to the hospital CEO and primary survey contact listed in the profile section of the online Leapfrog Hospital Survey.

For Hospitals that have not submitted a Leapfrog Hospital Survey by August 31, 2016 –

TBA – Letters sent to CEOs of hospitals receiving a Leapfrog Hospital Safety Grade.

Both e-mails and letters will include:

Information about the Leapfrog Hospital Safety Grade

Username/password to a secure website where hospitals can review the source data that Leapfrog used to calculate their numerical score

Links to the Hospital Safety Grade help desk and other helpful documents

September 14th – October 4th – Courtesy Safety Grade Review Period

End of October – Hospitals will be able to preview letter grades prior to the public release

End of October – Letter Grades will be published at www.HospitalSafetyGrade.org

For more information about important dates, visit: http://www.hospitalsafetyscore.org/for-hospitals/updates-and-timelines-for-hospitals

Proposed Updates to the 2017 Leapfrog Hospital Safety Grade

27

Spring 2017 ICU-only data will continue to be used for CLABSI and CAUTI in the

Spring 2017 Hospital Safety Grade.

The 2016 Leapfrog Hospital Survey will be the primary data source.

CMS Hospital Compare data published in October will be the secondary data source (October will be the last time CMS publishes ICU-only data for CLABSI/CAUTI).

Fall 2017 All unit data will be used for CLABSI and CAUTI in the Fall 2017 Hospital

Safety Grade.

2017 Leapfrog Hospital Survey will collect all unit data on CLABSI/CAUTI and this data will be used at the primary data source.

CMS Hospital Compare will be used as a secondary data source for CLABSI/CAUTI all unit data.

More Information28

Hospital Safety Score Help Desk: https://leapfrogscore.zendesk.com

Hospital Safety Score Website: www.HospitalSafetyScore.orgwww.HospitalSafetyGrade.org (live when new branding launches with release of letter grades at the end of October)

Notes 29

Please be sure to review Leapfrog’s policy on updating data used in the Hospital Safety Grade. A copy is available on the Data Review Website. Information is also included in the Data Review Instructions and Methodology document.

There is a typo on the Data Review Website, and in the Data Review Instructions and Methodology documents: The Reporting Period for the 5 infection measures from the

Leapfrog Hospital Survey is: 01/01/2015 – 12/31/2015

It is not 01/01/2015 – 12/30/2015

We cannot update this on the website or in the documents until the data review period has closed.

QUESTIONS?30