Leapfrog Hospital Survey

2017 Leapfrog Hospital Survey Hard CopyEndnotes & More Information

Leapfrog Hospital Survey

Hard Copy

QUESTIONS & REPORTING PERIODS

ENDNOTES

MEASURE SPECIFICATIONS

FAQS

Table of Contents

Welcome to the 2017 Leapfrog Hospital Survey6

Important Notes about the 2017 Survey6

Overview of the 2017 Leapfrog Hospital Survey7

Pre-Submission Checklist9

Instructions for Submitting a Leapfrog Hospital Survey10

Helpful Tips for Verifying Submission11

Tips for updating or correcting a previously submitted Leapfrog Hospital Survey11

Deadlines13

Deadlines for the 2017 Leapfrog Hospital Survey13

Deadlines to Join Leapfrogs NHSN Group13

Deadlines Related to the Hospital Safety Grade13

Technical Assistance14

Help Desk14

Leapfrog Survey Users Group14

Reporting Periods15

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PROFILE18

Profile19

Profile20

Facility Information20

Demographic Information20

Contact Information21

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SECTION 1: BASIC HOSPITAL INFORMATION24

Section 1: 2017 Basic Hospital Information25

1: Basic Hospital Information26

Section 1: 2017 Basic Hospital Reference Information28

Whats New in the 2017 Survey28

Change Summary since Release28

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SECTION 2: MEDICATION SAFETY - COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE)30

Section 2: 2017 Medication Safety - Computerized Physician Order Entry (CPOE)31

2: Medication Safety - Computerized Physician Order Entry (CPOE)32

Section 2: 2017 Medication Safety - Computerized Physician Order Entry Reference Information34

Whats New in the 2017 Survey34

Change Summary since Release34

CPOE Frequently Asked Questions (FAQs)35

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SECTION 3: INPATIENT SURGERY37

Section 3: 2017 Inpatient Surgery38

3A: Hospital and Surgeon Volume39

3B: Surgical Appropriateness46

Section 3: 2017 Inpatient Surgery Reference Information48

Whats New in the 2017 Survey48

Change Summary since Release48

Inpatient Surgery Measure Specifications Hospital and Surgeon Volume49

Carotid Endarterectomy Measure References50

Mitral Valve Repair and Replacement Measure References51

Open Aortic Aneurysm Repair Measure References52

Lung Resection Measure References53

Esophageal Resection Measure References55

Pancreatic Resection Measure References56

Rectal Cancer Surgery Measure References57

Hip Replacement Measure References58

Knee Replacement Measure References59

Bariatric Surgery for Weight Loss Measure References60

Inpatient Surgery Frequently Asked Questions (FAQs)62

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SECTION 4: MATERNITY CARE64

Section 4: 2017 Maternity Care65

4A Maternity Care Volume66

4B: Elective Deliveries67

4C: Cesarean Birth68

4D: Episiotomy69

4E: Process Measures of Quality70

4F:High-Risk Deliveries71

High-Risk Deliveries71

Neonatal Intensive Care Unit(s) Volume72

Neonatal Intensive Care Unit(s) National Performance Measurement72

Process Measure of Quality Antenatal Steroids73

Section 4: 2017 Maternity Care Reference Information75

Whats New in the 2017 Survey75

Change Summary since Release75

Maternity Care Measure Specifications76

Maternity Care Volume76

Elective Deliveries77

Cesarean Birth79

Episiotomy81

Maternity Care Process Measure Specifications82

Newborn Bilirubin Screening Prior to Discharge82

Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery83

High-Risk Deliveries Measure Specifications84

High-Risk Deliveries Volume Standard84

VON National Performance Measure Specifications85

Antenatal Steroids Process Measure86

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SECTION 5: ICU PHYSICIAN STAFFING (IPS)89

Section 5: 2017 ICU Physician Staffing (IPS) Standard90

5: ICU PHYSICIAN STAFFING (IPS)91

Section 5: 2017 ICU Physician Staffing (IPS) Reference Information94

Whats New in the 2017 Survey94

Change Summary since Release94

IPS Frequently Asked Questions (FAQs)95

General Questions95

Certification Questions95

Response Time Questions96

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SECTION 6: NQF Safe Practices99

Section 6: 2017 NQF Safe Practices100

6A: Practice #1 - Culture of Safety Leadership Structures and Systems102

6B: Practice #2 - Culture Measurement, Feedback, and Intervention104

6C: Practice #4 - Risks and Hazards106

6D: Practice #9 - Nursing Workforce108

6E: Practice #19 - Hand Hygiene110

Section 6: 2017 NQF Safe Practices Reference Information113

Whats New in the 2017 Survey113

Change Summary since Release113

Tips for Reporting on Section 6 Safe Practices114

Safe Practices Frequently Asked Questions (FAQs)115

General FAQs for the Safe Practices:115

FAQs Specific to Safe Practices117

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SECTION 7: MANAGING SERIOUS ERRORS124

Section 7: 2017 Managing Serious Errors125

7A: The Leapfrog Group Never Events Policy Statement126

7B: Healthcare-Associated Infections127

7C: Hospital-Acquired Conditions Pressure Ulcers and Injuries128

7D: Antibiotic Stewardship Practices129

Section 7: 2017 Managing Serious Errors Reference Information132

Whats New in the 2017 Survey132

Change Summary since Release132

Never Events Frequently Asked Questions (FAQs)133

Healthcare-Associated Infections Specifications135

Pressure Ulcers and Injuries Measure Specifications137

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SECTION 8: MEDICATION SAFETY139

Section 8: 2017 Medication Safety140

8A Bar Code Medication Administration141

8B: Medication Reconciliation143

Section 8: 2017 Medication Safety Reference Information145

Whats New in the 2017 Survey145

Change Summary since Release145

BCMA Frequently Asked Questions (FAQs)146

Medication Reconciliation Measure Specifications148

Medication Reconciliation Frequently Asked Questions (FAQs)150

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SECTION 9: PEDIATRIC CARE153

Section 9: 2017 Pediatric Care154

9A Patient Experience (CAHPS Child Hospital Survey)155

9B Pediatric Computed Tomography (CT) Radiation Dose158

Section 9: 2017 Pediatric Care Reference Information161

Whats New in the 2017 Survey161

Change Summary since Release161

Pediatric Computed Tomography (CT) Radiation Dose Specifications162

Pediatric CT Radiation Dose Frequently Asked Questions (FAQs)164

Endnotes and More Information165

21Version 7.0 First Release: April 1, 2017 Updated Release: April 5, 2017

Table of Contents

Welcome to the 2017 Leapfrog Hospital Survey

http://leapfroggroup.org/survey

Important Notes about the 2017 Survey

1. The Leapfrog Hospital Survey webpages are located at http://leapfroggroup.org/survey. Please bookmark this URL. You can also download a site map here.

2. Note the word hospital used throughout this survey refers to an individual hospital. If your hospital is part of a multi-hospital healthcare system or a multi-campus hospital, you will need to complete the survey for each individual hospital. Please refer to Leapfrogs Multi-Campus Hospital Reporting Policy.

3. Due to the update to the CPOE Evaluation Tool, the Tool will not be accessible from the Survey Dashboard until April 15. Adult hospitals that indicate they have a CPOE system in at least one inpatient unit are asked to demonstrate, via a test, that the inpatient CPOE system can alert physicians to at least 50% of common serious prescribing errors. Hospitals cannot access the CPOE Evaluation Tool until they have submitted Sections 1 Basic Hospital Information and 2 Medication Safety - CPOE of the online survey. More information about the CPOE Evaluation Tool, including instructions, scoring, and FAQs are available on the survey website. In addition, the CPOE Evaluation Tool was updated in 2017 to include new patient profiles and medication orders, as well as a redesigned user interface and updated time limits. All hospitals are urged to take a Sample Test prior to beginning an Adult Inpatient Test.

4. Adult and pediatric hospitals reporting on Section 7B Healthcare-Associated Infections are required to join Leapfrogs NHSN Group. More information, including important deadlines, is available on the Join NHSN Group webpage.

5. Leapfrog Hospital Survey Results will be available for hospitals to view on July 12 via the Hospital Details Page link on the Survey Dashboard. Survey Results will be posted to the public website on July 25 and then updated within the first 5 business days of each month to reflect surveys submitted or re-submitted between June 30 and December 31, and previously submitted surveys that were corrected before January 31. Survey Results are frozen from February to July 25.

6. All questions regarding the Leapfrog Hospital Survey should be submitted to the Help Desk at https://leapfroghospitalsurvey.zendesk.com. Questions submitted to the Help Desk will receive a respo