Overview of the Hospital Safety Score September 24, 2013

Missy Danforth, Senior Director of Hospital Ratings, The Leapfrog Group

Presentation Overview

• Who is getting a Hospital Safety Score?

• Changes to the Scoring Methodology Since May 2013 • New Measures

• Details of the data review process

• 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. This October will be the fourth 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

• More than 4 outcome measures 4

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 data sets

• 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

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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) 2013 Leapfrog Hospital Survey* 2012 HIT Supplement I*

ICU Physician Staffing (IPS) 2013 Leapfrog Hospital Survey* 2011 AHA Annual Survey i

Safe Practice 1: Leadership Structures and Systems 2013 Leapfrog Hospital Survey*

Safe Practice 2: Culture Measurement, Feedback and Intervention 2013 Leapfrog Hospital Survey*

Safe Practice 3: Teamwork Training and Skill Building 2013 Leapfrog Hospital Survey*

Safe Practice 4: Identification and Mitigation of Risks and Hazards 2013 Leapfrog Hospital Survey*

Safe Practice 9: Nursing Workforce 2013 Leapfrog Hospital Survey*

Safe Practice 17: Medication Reconciliation 2013 Leapfrog Hospital Survey*

Safe Practice 19: Hand Hygiene 2013 Leapfrog Hospital Survey*

Safe Practice 23: Care of the Ventilated Patient 2013 Leapfrog Hospital Survey*

SCIP INF 1: Antibiotic within 1 Hour CMS Hospital Compare*

SCIP INF 2: Antibiotic Selection CMS Hospital Compare*

SCIP INF 3: Antibiotic Discontinued After 24 Hours CMS Hospital Compare*

SCIP INF 9: Catheter Removal CMS Hospital Compare*

SCIP VTE 2: VTE Prophylaxis CMS Hospital Compare*

Outcome Measures (13)

Foreign Object Retained CMS HACs*

Air Embolism CMS HACs*

Pressure Ulcer – Stages 3 and 4 CMS HACs*

Falls and Trauma CMS HACs*

CLABSI 2013 Leapfrog Hospital Survey* CMS Hospital Compare*

CAUTI 2013 Leapfrog Hospital Survey CMS Hospital Compare

SSI: Colon CMS Hospital Compare

PSI 4: Death Among Surgical Inpatients CMS AHRQ PSI

PSI 6: Iatrogenic Pneumothorax CMS AHRQ PSI

PSI 11: Postoperative Respiratory Failure CMS AHRQ PSI*

PSI 12: Postoperative PE/DVT CMS AHRQ PSI

PSI 14: Postoperative Wound Dehiscence CMS AHRQ PSI

PSI 15: Accidental Puncture or Laceration CMS AHRQ PSI

[i] AHA Annual Survey © 2011 Health Forum, LLC *Updated Since May 2013

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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 and severity of harm to individual patients

• Weight score: [Evidence + (Opportunity x Impact)] 8

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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CHANGES TO THE SCORING METHODOLOGY SINCE MAY 2013

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Two New Measures

• CAUTI

• Primary Data Source: Leapfrog Hospital Survey

• Secondary Data Source: CMS HAI

• Data Element: SIR

• SSI: Colon

• Primary Data Source: CMS HAI

• Data Element: SIR

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DETAILS OF THE DATA REVIEW PROCESS

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Secure Website • http://www.leapfroggroup.org/data-validation/validation-

login

Details on what public reports were used to obtain source data. Links to source data with instructions.

Hospitals must confirm their Medicare Provider Number before moving on to the next page.

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Source Data

Instructions for hospital to review their source data and a link to the help desk

For each measure, hospitals are provided with the measure name, type of measure, data source (primary or secondary), reporting period, measure score (i.e. points, rate, SIR, etc)

Hospitals are asked to confirm that each Measure Score matches their score (i.e. rate, SIR, etc) from the Data Source (i.e. Leapfrog Hospital Survey Results, CMS Hospital Compare, etc)

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Where to Locate Source Data – Hospitals That Submitted a Leapfrog Hospital Survey by August 31, 2013

• CPOE: Visit www.leapfroggroup.org/cp, find the column labeled “prevent medication errors.” Leapfrog score used to determine points towards safety score (i.e. 4 bars equals 100 points, 3 bars equals 50 points, etc).

• ICU Physician Staffing: Visit www.leapfroggroup.org/cp, find the column labeled “Appropriate ICU Staffing.” Leapfrog score used to determine points towards safety score.

• CLABSI and CAUTI Standardized Infection Ratio (SIR): Visit www.leapfroggroup.org/cp, find the column labeled “prevent ICU infections.” The SIR was used to calculate in the safety score calculation, and is located in the first sentence in the first paragraph above the table.

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Where to find your hospital's CLABSI SIR on Leapfrog’s results website

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Where to Locate Source Data – Hospitals That Did Not Submit a Leapfrog Hospital Survey by August 31, 2013

• Safe Practice Points

• Log into your 2013 Leapfrog Hospital Survey

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Where to find your hospital’s CLABSI, CAUTI, SSI SIR on CMS’ results website

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Where to Locate Source Data – CMS Data for All Hospitals

• SCIP Measures: Hospital rates are published by CMS at https://data.medicare.gov/Hospital-Compare/Hospital-Process-of-Care-Measures-Surgical-Care-Im/iz5u-4mk2

• HACs: Use the downloadable database on the Data Preview Website

• PSI 11: Use the downloadable database on the Data Preview Website

• Other PSIs: Hospital rates are published by CMS at https://data.medicare.gov/Hospital-Compare/Agency-For-Healthcare-Research-And-Quality-Measure/vs3q-rxc5

• You can download your hospital’s results into a CSV or XLS formatted file.

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Where to Locate Source Data – AHA Data for Hospitals That Did Not Complete a Leapfrog Hospital Survey by August 31, 2013

• ICU Physician Staffing - 2011 AHA Annual Survey

• CPOE – 2012 HIT Supplement

• Please contact AHA Health Forum

• Please note: corrects will only be accepted to through October 7th

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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

• September 2013 - 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

• September 19 – October 7- Courtesy Data Preview Period

• Mid-October – Hospitals will be able to preview letter grades 48 hours

prior to the pubic release (www.HospitalSafetyScore.org). • Late October – 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

• Data Review Website - http://www.leapfroggroup.org/data-validation/validation-login

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