data review instructions - hospitalsafetygrade · spring 2016 data review instructions last updated...

Data Review Instructions SPRING 2016 DATA REVIEW PERIOD (MARCH 2 – MARCH 23, 2016)

Spring 2016 Data Review Instructions Last Updated 03/02/2016 1

TABLE OF CONTENTS

GETTING STARTED ................................................................................................................................................................................................................................ 2

SOURCE DATA ....................................................................................................................................................................................................................................... 2

INSTRUCTIONS ...................................................................................................................................................................................................................................... 4

CONTACT INFORMATION.............................................................................................................................................................................................................. 4

HOSPITAL SOURCE DATA .............................................................................................................................................................................................................. 4

HOSPITAL SAFETY SCORE .............................................................................................................................................................................................................. 5

LEAPFROG HOSPITAL SURVEY RESULTS ........................................................................................................................................................................................ 5

LINKS TO SOURCE DATA ....................................................................................................................................................................................................................... 5

LEAPFROG MEASURES ...................................................................................................................................................................................................................... 6

CMS MEASURES ................................................................................................................................................................................................................................ 9

NOTE ABOUT EXTREME VALUES ......................................................................................................................................................................................................... 12


GETTING STARTED

The website address for the Data Review Website is: www.hospitalsafetyscore.org/data-review. You’ll need a username and password to access this secure

website. If your hospital submitted a 2015 Leapfrog Hospital Survey by December 31, 2015, the username and password was emailed to your hospital’s CEO

and survey contact. If your hospital did not submit a 2015 Leapfrog Hospital Survey, the username and password was mailed to your hospital’s CEO. Usernames

and passwords have not changed since Fall 2015.

If you cannot locate your login credentials, contact the Help Desk at https://leapfrogscore.zendesk.com. To avoid delays, please ensure that your help desk

ticket includes the following information: (1) Your hospital’s name, (2) Physical address, and (3) Medicare Provider Number.

SOURCE DATA

The Data Snapshot date for the spring’s update to the Hospital Safety Score was February 15, 2016. Leapfrog obtained data from the following sources to

calculate Hospital Safety Scores.

Data Source Measures Reporting Period

2015 Leapfrog Hospital Survey Results

Computerized Physician Order Entry (CPOE) * 01/01/2014-06/30/2015

ICU Physician Staffing (IPS) * 01/01/2014-06/30/2015

NQF Safe Practices * SP1 Leadership Structures and Systems SP2 Culture Feedback, Measurement, & Intervention SP 3 Teamwork Training & Skill Building SP 4 Identification & Mitigation of Risks/Hazards SP 9 Nursing Workforce SP 17 Medication Reconciliation SP 19 Hand Hygiene SP 23 Care of the Ventilated Patient

01/01/2014-06/30/2015

Central-line Associated Blood Stream Infections (in ICUs only) * 01/01/2014-06/30/2015

Catheter-associated Urinary Tract Infections (in ICUs only) * 01/01/2014-06/30/2015

http://www.hospitalsafetyscore.org/data-review


Data Source Measures Reporting Period

Centers for Medicare and Medicaid Services (CMS)

Survey of Patients’ Experiences# H-COMP-1 Nurse Communication H-COMP-2 Doctor Communication H-COMP-3 Staff Responsiveness H-COMP-5 Communication about Medicines H-COMP-6 Discharge Information

04/01/2014-03/31/2015

Central-line Associated Blood Stream Infections (in IUCs only)* 04/01/2014-03/31/2015

Catheter-associated Urinary Tract Infections (in ICUs only)* 04/01/2014-03/31/2015

Surgical Site Infection: Major Colon Surgery* 04/01/2014-03/31/2015

MRSA Blood Laboratory-identified Events# 04/01/2014-03/31/2015

C. diff. Laboratory-identified Events# 04/01/2014-03/31/2015

AHRQ Patient Safety Indicators PSI 3 Pressure Ulcer PSI 4 Death from Serious Treatable Complications after Surgery PSI 6 Iatrogenic Pneumothorax PSI 12 Postoperative PE/DVT PSI 14 Postoperative Wound Dehiscence PSI 15 Accidental Puncture or Laceration

07/01/2012-06/30/2014

PSI 11 Postoperative Respiratory Failure 07/01/2011-06/30/2013

Hospital-Acquired Conditions Foreign Object Retained Air Embolism Falls/Trauma

07/01/2011-06/30/2013

AHA Annual Survey & HIT Supplement Computerized Physician Order Entry 2014

ICU Physician Staffing* 2014

*Updated since the Fall 2015 Hospital Safety Score. This measure was ONLY used if your hospital did NOT submit a 2015 Leapfrog Hospital Survey. #This measure is new to the Hospital Safety Score.


INSTRUCTIONS

Once you have a copy of your username and password, log in to the secure Data Review Website at: www.hospitalsafetyscore.org/data-review.

CONTACT INFORMATION

1. Review the name and address we have displayed for your hospital. If this information is not correct, please provide updated information.

Note: The updated name and address you provide will appear exactly as you enter it on the public reporting website

(www.hospitalsafetyscore.org). Do not use abbreviations or enter post office boxes.

2. Confirm your Medicare Provider Number. If the number displayed is not correct, please contact the Help Desk immediately at

https://leapfrogscore.zendesk.com.

3. Provide the most current and accurate contact information for your CEO. The email address you provide will be used to send important

notifications about the Hospital Safety Score.

4. If your hospital is not a general, short-term, acute care hospital, and you believe you should be excluded from receiving a Hospital Safety

Score based on your hospital’s primary service type, please contact the Help Desk immediately.

5. Review the information you have entered to make sure it is correct, and then click on the “Click here to continue” button. On the next page

you’ll be able to review your source data, where you will provide the most current and accurate contact information for the data reviewer.

HOSPITAL SOURCE DATA

1. Using the information in the source data table, you can compare the measure score that Leapfrog has recorded with the measure score from

the public report. Be sure to carefully check the data source listed in the table before you begin the data review process.

2. You can access each of the web-based reports referenced in the source data table in the “Links to Source Data” section of this document.

3. If the score for each measure matches the public report, click “Yes” in the last column of the source data table. If the value does not match

the public report, click “No,” and contact the Help Desk immediately. The Help Desk will need to know which measure and score you are

inquiring about, and they will need a copy of the public report (screen shot) that shows a different score than the one Leapfrog has

recorded. Please double check the data source, measure name, and reporting period before you contact the Help Desk.

http://www.hospitalsafetyscore.org/data-review

http://www.hospitalsafetyscore.org/

https://leapfrogscore.zendesk.com/


4. After reviewing the score for each measure, please provide contact information in the “Reviewer Information” fields at the bottom of the

page.

5. After verifying that all the information that you have provided is correct, click on the “Click here to continue” button. On the next page you’ll

be able to review your preliminary numerical score and related documents.

HOSPITAL SAFETY SCORE

1. Using the source data on the data review page, Leapfrog has calculated a preliminary numerical Safety Score for your hospital. This numerical

score will later be finalized and then translated into a letter grade.

2. Please remember that the numerical Safety Scores posted during the Data Review Period are preliminary as changes do occur during the

Data Review Period. Final numerical Safety Scores will be posted, along with the letter grade, 48 hours prior to the public announcement.

Hospitals will be alerted via email.

3. Leapfrog has provided links to the Scoring Methodology and a calculator so you can better understand how your score was calculated. If any

of the source data on the previous page did not match your hospital’s public report and you submitted a ticket to the Help Desk, the Help

Desk will follow up with you directly.

LEAPFROG HOSPITAL SURVEY RESULTS

If your hospital did not complete a 2015 Leapfrog Hospital Survey by December 31, 2015, Leapfrog measures were not used to calculate your Hospital Safety

Score. Leapfrog will update Hospital Safety Scores again in the fall of 2016. If your hospital would like Leapfrog Hospital Survey data included in the next

Hospital Safety Score, a 2016 Leapfrog Hospital Survey must be submitted by August 31, 2016.

For more information about the Leapfrog Hospital Survey, visit https://leapfroghospitalsurvey.org.

LINKS TO SOURCE DATA

Hospitals can verify that Leapfrog recorded the correct measure score from each public report using the links provided in the tables below. Please refer to the

'Data Source' column on the Data Review Website before selecting a public report from the tables below. If the 'Data Source' is listed as the 2015 Leapfrog

Hospital Survey or AHA Annual Survey, see the 'Leapfrog Measures' table for the data source information. If the 'Data Source' is listed as CMS, see the 'CMS

Measures' table below.

https://leapfroghospitalsurvey.org/


LEAPFROG MEASURES

NOTE ABOUT REPORTING PERIODS

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. Therefore, the reporting period for the Leapfrog Hospital Survey is listed as 01/01/2014 - 6/30/2015 to account for responses submitted by the Data

Snapshot Date: February 15, 2015. For questions about Leapfrog Hospital Survey reporting periods, please contact the Help Desk at

https://leapfrogscore.zendesk.com.

CPOE, ICU PHYSICIAN STAFFING, CLABSI AND CAUTI

If your hospital submitted Section 2 CPOE and/or Section 5 ICU Physician Staffing of the 2015 Leapfrog Hospital Survey, the survey results for those sections are

translated into numerical point values for the purposes of the Hospital Safety Score. If these sections were not submitted, then the AHA annual survey was

used as a secondary data source for these measures (see ‘Uses of Secondary Data’ in the Scoring Methodology).

Leapfrog Performance Category Displayed on Leapfrog’s Public

Reporting Website www.leapfroggroup.org/cp

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’

https://leapfrogscore.zendesk.com/

http://www.leapfroggroup.org/cp


Measure Reporting

Period Data Sources URL to view hospital data Notes

Computerized Physician Order Entry (CPOE)

01/01/2014-06/30/2015

2015 Leapfrog Hospital Survey

www.leapfroggroup.org/cp

Under the "General Information" tab, see column labeled “Doctors order medications through a computer”

2014 AHA HIT Supplement www.ahasurvey.org Contact the AHA Health Forum for a copy of your 2014 HIT Supplement

ICU Physician Staffing (IPS)

01/01/2014-06/30/2015



Under the "General Information" tab, see column labeled "Specially trained doctors care for ICU patients"

2014 AHA Annual Survey www.ahasurvey.org Contact the AHA Health Forum for a copy of your 2014 AHA Annual Survey.

Safe Practice 1: Leadership Structures and Systems

01/01/2014-06/30/2015


www.leapfroghospitalsurvey.org

Log in to your hospital's survey and view your Hospital Detail Pages to find Safe Practices' scores.

Safe Practice 2: Culture Measurement, Feedback and

Intervention

01/01/2014-06/30/2015




Safe Practice 3: Teamwork Training and Skill Building

01/01/2014-06/30/2015




Safe Practice 4: Identification and Mitigation

of Risks and Hazards

01/01/2014-06/30/2015




Safe Practice 9: Nursing Workforce

01/01/2014-06/30/2015





http://www.ahasurvey.org/


http://www.ahasurvey.org/

http://www.leapfroghospitalsurvey.org/






Measure Reporting

Period Data Sources URL to view hospital data Notes

Safe Practice 17: Medication Reconciliation

01/01/2014-06/30/2015




Safe Practice 19: Hand Hygiene

01/01/2014-06/30/2015




Safe Practice 23: Care of the Ventilated Patient

01/01/2014-06/30/2015




CLABSI 01/01/2014-06/30/2015



Under the "Hospital-Acquired Conditions" tab, see the column labeled "Reduce Central-Line Infections in ICUs." Click the '?' and see the standardized infection ratio above the table. If your hospital submitted Section 7 Managing Serious Errors of the 2015 Leapfrog Hospital Survey, but received a score of “Unable to Calculate Score” for CLABSI, refer to the CMS Measures table (and ‘Uses of Secondary Data’ in the Scoring Methodology).

CAUTI 01/01/2014-06/30/2015



Under the "Hospital-Acquired Conditions" tab, see the column labeled "Reduce Urinary Catheter Infections in ICUs." Click the '?' and see the standardized infection ratio above the table. If your hospital submitted Section 7 Managing Serious Errors of the 2015 Leapfrog Hospital Survey, but received a score of “Unable to Calculate Score” for CAUTI, refer to the CMS Measures table (and ‘Uses of Secondary Data’ in the Scoring Methodology).





CMS MEASURES

Use the links provided in the table below to access the public reports for each of the CMS measures used in the Spring 2016 Hospital Safety Score.

When searching for your hospital’s measure scores on the CMS websites, enter your hospital’s Medicare Provider Number (without the dash, but including the

leading zero if applicable) in the “Find in this Dataset” search box, which is highlighted in red in the screen shot below. Next, look in the Measure ID column for

the corresponding CMS Measure ID listed in the table below, and view the score or rate for that row.

Hospital Safety Score Measure Name

CMS Measure ID Reporting Period Data Sources URL to view hospital data

H-COMP-1: Nurse Communication

H_COMP_1_STAR_RATING 04/01/2014-03/31/2015

CMS https://data.medicare.gov/Hospital-Compare/Patient-survey-

HCAHPS-Hospital/dgck-syfz

H-COMP-2: Doctor Communication


CMS https://data.medicare.gov/Hospital-Compare/Patient-survey-HCAHPS-Hospital/dgck-syfz

H-COMP-3: Staff Responsiveness



H-COMP-5: Communication about

Medicines



H-COMP-6: Discharge Information



https://data.medicare.gov/Hospital-Compare/Patient-survey-HCAHPS-Hospital/dgck-syfz













Foreign Object N/A 07/01/2011-06/30/2013

CMS https://data.cms.gov/dataset/Deficit-Reduction-Act-DRA-Hospital-Acquired-Condit/k45g-we4e

Air Embolism N/A 07/01/2011-06/30/2013


Falls and Trauma N/A 07/01/2011-06/30/2013


CLABSI (ICU only)

HAI_1a_SIR 04/01/2014-03/31/2015

CMS https://data.medicare.gov/Hospital-Compare/Healthcare-

Associated-Infections-Hospital/77hc-ibv8

ONLY if your hospital did not submit a 2015 Leapfrog Hospital Survey. If your hospital did submit a 2015 Leapfrog Hospital

Survey, see Leapfrog Measures.

CAUTI (ICU only)

HAI_2a_SIR 04/01/2014-03/31/2015

CMS

https://data.medicare.gov/Hospital-Compare/Healthcare-Associated-Infections-Hospital/77hc-ibv8

ONLY if your hospital did not submit a 2015 Leapfrog Hospital Survey. If your hospital did submit a 2015 Leapfrog Hospital

Survey, see Leapfrog Measures.

SSI: Colon HAI_3_SIR 04/01/2014-03/31/2015



MRSA HAI_5_SIR 04/01/2014-03/31/2015



C. Diff. HAI_6_SIR 04/01/2014-03/31/2015



PSI 3: Pressure Ulcer PSI-3 07/01/2012-06/30/2014

CMS https://data.cms.gov/dataset/Provider-Level-Measure-Rates-

for-Component-Indicat/a36t-qs8j

https://data.cms.gov/dataset/Deficit-Reduction-Act-DRA-Hospital-Acquired-Condit/k45g-we4e
















https://data.cms.gov/dataset/Provider-Level-Measure-Rates-for-Component-Indicat/a36t-qs8j





PSI 4: Deaths among Patients with Serious

Treatable Complications after Surgery

PSI_4_SURG_COMP 07/01/2012-06/30/2014

CMS https://data.medicare.gov/Hospital-Compare/Complications-

Hospital/632h-zaca

PSI 6: Iatrogenic Pneumothorax

PSI-6 07/01/2012-06/30/2014



PSI 11: Postoperative Respiratory Failure

n/a 07/01/2011 -06/30/2013


for-AHRQ-Patient-Safe/mxxa-syy6

PSI 12: Postoperative PE/DVT

PSI-12 07/01/2012-06/30/2014



PSI 14: Postoperative Wound Dehiscence

PSI-14 07/01/2012-06/30/2014



PSI 15: Accidental Puncture or Laceration

PSI-15 07/01/2012-06/30/2014



https://data.medicare.gov/Hospital-Compare/Complications-Hospital/632h-zaca

https://data.medicare.gov/Hospital-Compare/Complications-Hospital/632h-zaca



https://data.cms.gov/dataset/Provider-Level-Measure-Rates-for-AHRQ-Patient-Safe/mxxa-syy6

https://data.cms.gov/dataset/Provider-Level-Measure-Rates-for-AHRQ-Patient-Safe/mxxa-syy6








NOTE ABOUT EXTREME VALUES

For hospitals that have an “extreme” value for a particular measure (e.g. a value that exceeds the 99th percentile) Leapfrog “trims” the reported value to the

99th percentile. For example, if CMS has reported a rate of 0.50 per 1,000 patient discharges for the Foreign Object Retained measure for your hospital,

Leapfrog has “trimmed” this rate to 0.403 (e.g. the 99th percentile). Therefore, on the Hospital Safety Score website, you’ll see the measure score for Foreign

Object Retained displayed as 0.403. Please see the table below for a list of the “trim” values for the Spring 2016 Hospital Safety Score.

Measure 99th Percentile

Foreign Object Retained 0.403

Air Embolism 0.117

Falls and Trauma 2.667

CLABSI 2.273

CAUTI 3.281

SSI: Colon 3.333

MRSA 3.577

C. Diff. 2.111

PSI 3: Pressure Ulcer 1.82

PSI 4: Death from Serious Treatable Complications after Surgery 167.33

PSI 6: Iatrogenic Pneumothorax 0.64

PSI 11: Postoperative Respiratory Failure 24.29

PSI 12: Postoperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) 10.12

PSI 14: Postoperative Wound Dehiscence 2.86

PSI 15: Accidental Puncture or Laceration 3.91

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