Overview of the Spring 2016 Hospital Safety Score March 7, 2016

Missy Danforth, Vice President of Hospital Ratings, The Leapfrog Group

Presentation Overview

• Who is getting a Hospital Safety Score?

• Scoring Overview

• Details of the Courtesy Data Review Period

• Important Dates

• Questions

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What is the Hospital Safety Score?

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

• The Hospital Safety Score launched in June 2012. The score is issued two times per year: April and October. This spring will be the ninth release.

• More information at www.HospitalSafetyScore.org

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What Hospitals Will Receive a Hospital Safety Score? • General, acute-care hospitals for which there is adequate

public data

• Excluded Hospitals include: • 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

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SCORING OVERVIEW 5

Measure Selection Criteria

• Measures are publicly-reported from national data sources, reflecting individual hospital results

• Leapfrog Hospital Survey

• Centers for Medicare and Medicaid Services

• 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 6

Changes to the Measure Set • The scoring methodology for the 2016 Hospital Safety Score has been updated to remove

five measures and add seven new measures. The Blue Ribbon Expert Panel has recommended, and Leapfrog's Board of Directors has approved the following changes:

• Five Surgical Care Improvement Project (SCIP) measures will be removed: • Antibiotic within 1 Hour (SCIP INF 1) • Antibiotic Selection (SCIP INF 2) • Antibiotic Discontinued After 24 Hours (SCIP INF 3) • Catheter Removal (SCIP INF 9) • VTE Prophylaxis (SCIP VTE 2)

• Five HCAHPS measures used in the CMS Inpatient Quality Reporting Program will be added: • Nurse Communication (H-COMP-1) • Doctor Communication (H-COMP-2) • Staff Responsiveness (H-COMP-3) • Communication about Medicines (H-COMP-5) • Discharge Information (H-COMP-6)

• Two Healthcare-Associated Infection measures used in the CMS Inpatient Quality Reporting Program will be added: • MRSA • C. diff

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Measures included in the Hospital Safety Score Measure Name Primary Data Source Secondary Data Source

Process and Structural Measures (15)

Computerized Physician Order Entry (CPOE) 2015 Leapfrog Hospital Survey 2014 HIT Supplement I

ICU Physician Staffing (IPS) 2015 Leapfrog Hospital Survey 2014 AHA Annual Survey I

Safe Practice 1: Leadership Structures and Systems 2015 Leapfrog Hospital Survey

Safe Practice 2: Culture Measurement, Feedback and Intervention 2015 Leapfrog Hospital Survey

Safe Practice 3: Teamwork Training and Skill Building 2015 Leapfrog Hospital Survey

Safe Practice 4: Identification and Mitigation of Risks and Hazards 2015 Leapfrog Hospital Survey

Safe Practice 9: Nursing Workforce 2015 Leapfrog Hospital Survey

Safe Practice 17: Medication Reconciliation 2015 Leapfrog Hospital Survey

Safe Practice 19: Hand Hygiene 2015 Leapfrog Hospital Survey

Safe Practice 23: Care of the Ventilated Patient 2015 Leapfrog Hospital Survey

H-COMP-1: Nurse Communication CMS *

H-COMP-2:Doctor Communication CMS *

H-COMP-3: Staff Responsiveness CMS *

H-COMP-5: Communication about Medicines CMS *

H-COMP-6: Discharge Information CMS *

Outcome Measures (15)

Foreign Object Retained CMS

Air Embolism CMS

Falls and Trauma CMS

CLABSI 2015 Leapfrog Hospital Survey CMS

CAUTI 2015 Leapfrog Hospital Survey CMS

SSI: Colon CMS

MRSA CMS*

C. Diff. CMS*

PSI 3: Pressure Ulcer CMS

PSI 4: Death Among Surgical Inpatients CMS

PSI 6: Iatrogenic Pneumothorax CMS

PSI 11: Postoperative Respiratory Failure CMS

PSI 12: Postoperative PE/DVT CMS

PSI 14: Postoperative Wound Dehiscence CMS

PSI 15: Accidental Puncture or Laceration CMS

[i] AHA Annual Survey © 2014 Health Forum, LLC *New in 2016

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Measure Highlights

• Several measures have been updated since the October 2015 score including: • Leapfrog Hospital Survey Results for CPOE, ICU Physician Staffing,

NQF Safe Practices, CLABSI, and CAUTI

• All CMS infection measures (CLABSI, CAUTI, SSI Colon, MRSA, C. Diff.)

• AHA Annual Survey Results for ICU Physician Staffing

• For the Fall 2016 Hospital Safety Score we anticipate making the 2016 Leapfrog Hospital Survey the primary data source for: • SSI Colon

• MRSA

• C. Diff 9

A note about reporting periods

• Leapfrog Hospital Survey Measures • The 2015 Leapfrog Hospital Survey includes two reporting

periods.

• Hospitals that submit a survey before September 1, 2015 were asked to report on the 12-months ending December 31, 2014.

• Hospitals that submit a survey on or after September 1, 2015 were asked to report on the 12-months ending June 30, 2015.

• Because the data snapshot date is February 15, 2016, the reporting period for the Leapfrog Hospital Survey will be listed as 01/01/2014 – 06/30/2015 for all Leapfrog Hospital Survey measures.

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

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Weighting Process • Two (2) measure domains, each weighted 50%:

1. Process/structural measures

2. Outcome measures

• Three (3) 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, or 3) based on:

• no. 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)] 11

Z-Score Methodology

• 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 always equals 0; worse than mean = negative z-score ; better than mean = positive z-score

• Translate raw score on measure to z-score: • Process/Structural Measures = [(Hospital Score – Mean)/Standard

Deviation]

• Outcome Measures = [(Mean – Hospital Score)/Standard Deviation]

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Overall Score

• Summation of z-score for each measure × weight for each measure

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

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

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

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DETAILS OF THE DATA REVIEW PROCESS

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Secure Website • http://www.HospitalSafetyScore.org/data-review

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Contact Information

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Source Data

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What if the Measure Score doesn’t match the public report?

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

• Hospitals must provide a copy

of the public report that shows a different score

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

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Preview Numerical Safety Score

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Important Dates • February 15th – Data Snapshot Date • For hospitals that have submitted a Leapfrog Hospital Survey by December 31, 2015 –

• Email will be sent to the hospital CEO and survey contact listed in the Profile section of the online Leapfrog Hospital Survey.

• The email will include: • Information about the Hospital Safety Score • A username/password to a secure website where hospitals can review the source data that Leapfrog used to

calculate their numerical safety score • Links to the Hospital Safety Score help desk and helpful documents

• For hospitals that have NOT submitted a Leapfrog Hospitals survey by December 31, 2015 –

• Letter sent to CEOs of hospitals receiving a Hospital Safety Score. Letter included: • Information about the Hospital Safety Score • A username/password to a secure website where hospitals can review the source data that Leapfrog used to

calculate their numerical safety score • Links to the Hospital Safety Score help desk and helpful documents

• March 2 – 23, 2016 Courtesy Data Preview Period

• End of April – Hospitals will be able to preview letter grades 48 hours prior to the pubic release

(www.HospitalSafetyScore.org). • End of April – Letter Grades will be published at www.HospitalSafetyScore.org.

• For more information about important dates, visit: http://www.hospitalsafetyscore.org/for-

hospitals/updates-and-timelines-for-hospitals

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More Information

• Hospital Safety Score Help Desk - scorehelp@leapfroggroup.org

• Hospital Safety Score Website – www.HospitalSafetyScore.org

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