1. 1 1 What’s New in 2014: The Leapfrog Hospital Survey Town Hall Calls May 13, 2014 and May 28, 2014

2. 2 2 Town Hall Call Overview Introduction –Goals for 2014 survey Survey Submission –Online survey and logistics –Website resources –Timeline What’s New for 2014 –Online Survey Tool – Quick Start Guide –Section 2: CPOE Evaluation Tool –Section 3: Evidence-based Hospital Referral (EBHR) –Section 4: Maternity Care –Section 5: ICU Physician Staffing (IPS) –Section 6: NQF Safe Practices –Section 7: Hospital Acquired Conditions (HACs) –Section 8: Safety Focused Scheduling –Section 9: Resource Use for Common Acute Conditions How Results are Displayed and Used by Others Q & A

3. 33 Survey Review Process Steps in the process to revise the survey have included: (August/September 2013) Staff and expert panelist set goals, review latest measures, review changes to endorsement status, consider member and hospital recommendations from the previous year (November, 2013) Publish proposed changes for public comment period – hospitals and other stakeholders invited to share comments and feedback on the proposed changes for the 2014 survey (January, 2014) Pilot test of revised survey where hospitals are asked to test a draft of the 2014 survey and provide feedback

4. 4 Behind the Changes Goals for the survey— 1.Expand survey to more hospitals 2.Keep reporting burden as low as possible 3.Continue alignment with other performance measurement groups (such as CDC-NHSN; CMS; The Joint Commission) 4.Include cutting-edge measures that improve the safety, quality, and efficiency of care delivery 5.Maintain consistent measurement structure for LHRP and for improvement purposes 6.Update measures with guideline changes 7.Add new performance measurement entities 8.Maintain measures meaningful to purchasers and consumers

5. 5 How did we do? Bulk of survey remains identical to the 2013 survey, including the performance cut-points for several measures Added two measures, but neither will be publicly reported in 2014: NTSV Cesarean Section and OR Access Added some exploratory questions at the end of Section 6 regarding culture of safety surveys. Removed AAA process measure Updated measure specifications to maintain alignment with other measurement entities (CMS, The Joint Commission)

6. 66 Survey Submission Logistics, Website Resources, and Timeline

7. 77 Survey Security and Integrity Core principle: hospital self-certification via affirmation Executive authority and accountability Survey security and integrity are critical: –16-digit security code Authorization to access granted only to: –CEO... can provide code directly to any delegate(s) –CEO-authorized delegate... Help Desk can email security codes. See survey website, “Get a Security Code”

8. 88 Website Resources Survey home page at www.leapfroghospitalsurvey.org includes links to:www.leapfroghospitalsurvey.org 2014 Quick Start Guide Request a security code Hardcopy of the survey Leapfrog Hospital Survey Reference Book –Measure specifications –Frequently Asked Questions –Scoring Algorithms –Changes since initial release 4/1/2014 Other links on home page –“What’s New in 2014” –Survey deadlines –Excel tool for computing Geometric Mean Length of Stay, SIR, and Adjusted C-section Rate –Supplemental info re: Resource Utilization scoring and Survival Predictors –Fact sheets –White Papers on Severity-adjustment for LOS and Survival Predictor

9. Download Survey Materials 9

10. Survey Dashboard 10 Only appears once you have submitted a survey. Always print a copy of your last submitted survey and review it for accuracy and completeness. Only appears once you have saved a survey. Remember, saved survey responses are not scored. NEW THIS YEAR!

11. Survey Dashboard PROFILE – The profile page includes all of the information in Section 1 of the Leapfrog Hospital Survey. Certain fields on the profile page will be pre-populated, but all of the fields are editable so that you can update your hospital name, address, Medicare Provider Number, CEO, survey contact, and other information at any time. ONLINE SURVEY – Once you complete and save the profile page, the Online Survey button will appear on the dashboard. By selecting the Online Survey button, you will be able to access Sections 2-9 of the Leapfrog Hospital Survey. CPOE EVALUATION TOOL – If your hospital has implemented CPOE and you would like to access the CPOE Evaluation Tool, you must first (a) complete section 2 of the survey, (b) affirm section 2 of the survey, and (c) submit section 2 of the survey. You can log back in to the survey to complete the remaining sections of the survey (3-9) at any time. PRINT LAST SAVED SURVEY – Generates a PDF document that includes any responses that have been entered and saved. PRINT LAST SUBMITTED SURVEY – Generates a PDF document that includes any responses that have been submitted. As a reminder, a section must be completed and affirmed, before it can be submitted. PRINT LAST SUBMITTED 2013 SURVEY – Generates a PDF document that includes responses from your Last Submitted 2013 Leapfrog Hospital Survey. DETAILS – After July 25 th, when Leapfrog publishes the first Leapfrog Hospital Survey Results on its public reporting website, www.leapfroggroup.org/cp, hospitals will be able to access the details page from the dashboard. The details page includes information about resource use scoring, survival predictor scoring, and safe practice scoring that is not published.www.leapfroggroup.org/cp 11

12. Survey Legend 12

13. 13 Survey Helpdesk Available Survey Help Desk -- responds within 24-48 hours (unless expert panel advise is needed) Link on survey homepage leapfroghospitalsurvey.zendesk.com Tips: –Section 2 of the survey must be submitted before CPOE Evaluation Tool is taken. –Don’t wait. Leapfrog’s deadlines are firm.

14. 14 2014 Important Dates April 1st – 2014 survey opens June 30th – first reporting deadline – hospitals that do not submit a survey by this date will be reported as “Declined to Respond” July 25 th - Leapfrog website lists new results (www.leapfroggroup.org/cp) August 31 st – –Hospital Safety Score data snapshot date –Top Hospitals –LHRP December 31 st – deadline for the 2014 survey (no new surveys or CPOE tests can be submitted after this date) January 31 st – end of correction period; 2014 survey closes Feb – July – 2014 results frozen on leapfroggroup.org/cp

15. 15 What’s New for 2014

16. 16 Section 2: Computerized Prescriber Order Entry Change: Extended the amount of time hospitals have to complete steps 4 and 5 of the CPOE Evaluation Tool (i.e., enter the orders, record advice/information, enter final results, and submit results). Reasoning: Hospitals have requested additional time to enter orders into their CPOE System. Previously, hospitals were allowed 2 hours to complete steps 4 and 5. Hospitals will now have 2.5 hours to complete steps 4 and 5, with a 30-minute time limit for step 5. Hospitals will continue to have 4 hours to complete steps 1-3. For more information on the CPOE Evaluation Tool, visit https://leapfroghospitalsurvey.org/cpoe- evaluation-tool/.https://leapfroghospitalsurvey.org/cpoe- evaluation-tool/ Impact: Previously, hospitals were allowed 2 hours to complete steps 4 and 5. Hospitals will now have 2.5 hours to complete steps 4 and 5, with a 30-minute time limit for step 5. Hospitals will continue to have 4 hours to complete steps 1-3. For more information on the CPOE Evaluation Tool, visit https://leapfroghospitalsurvey.org/cpoe- evaluation-tool/.https://leapfroghospitalsurvey.org/cpoe- evaluation-tool/

17. 17 Section 3: Evidence Based Hospital Referral (EBHR) Change: Removed AAA Process Measures (SCIP-Card 2) from Section 3B. Reasoning: Over the past several years, the number of AAA’s repaired via endovascular procedures have significantly increased. These endovascular procedures are typically lower risk than traditional open repair, and the importance of beta blockers has not been well studied within this group of patients. Impact: Hospitals will be simply scored on the predicted survival of patients undergoing this procedure at their hospital. The AAA scoring algorithm will mirror how hospitals have been scored on the Pancreatectomy and Esophogectomy subsections of the survey.

18. 18 Section 3: Evidence Based Hospital Referral (EBHR) Change: Replaced Leapfrog’s Antenatal Steroids Measure with The Joint Commissions PC-03 Antenatal Steroids Measure. Rationale: For several years, Leapfrog has given hospitals two options when reporting on the administration of antenatal steroids to women prior to delivery of very low birth-weight babies: (1) hospitals could report data submitted to the Vermont Oxford Network or (2) use Leapfrog’s measure specifications, which closely align with the Vermont Oxford Network. With changes to The Joint Commissions mandatory reporting requirements, Leapfrog has decided to replace the second option (Leapfrog’s own measure specifications) with the Joint Commission’s PC-03 Antenatal Steroids measure. Impact: Hospitals will continue to have the option of reporting data submitted to the Vermont Oxford Network. The scoring algorithm for this section will remain unchanged. The target for all hospitals on the antenatal steroid measure will remain 80% or greater adherence.

19. 19 Section 4: Maternity Care Change: Addition of NTSV Cesarean Section Measure. Rationale: The NTSV cesarean section delivery measure focuses attention on a population of women who are low-risk and delivering for the first time. Unlike other cesarean section delivery measures, the NTSV cesarean section delivery rate is associated with concrete quality improvement activities that can be performed to address the differences in cesarean delivery rates among hospitals. These quality improvement activities include reducing admissions in early labor and eliminating elective labor induction before 41 weeks in the first births. Impact: All hospitals reporting at least 50 births annually will be asked to provide their NTSV cesarean section delivery data on the Maternity Care section. Leapfrog will collect hospital responses to the new NTSV cesarean section delivery measure and score hospitals accordingly. However, individual hospital rates will not be publicly reported on the Leapfrog’s Hospital Survey Results website until 2015. In 2014, hospitals will only be able to view their results for this measure on their password-protected “Details” page. In 2015, Leapfrog plans to publicly report individual hospital results on the NTSV cesarean section delivery rate measure on the Leapfrog Hospital Survey Results website.

20. 20 Section 5: ICU Physician Staffing Change: Hospitals have the opportunity to earn partial credit on the IPS standard if the hospital has physicians certified in critical care medicine managing or co-managing ICU patients for at least 4 hours per day, 7 days per week. The physicians providing this care must be ordinarily present on- site in these units and provide clinical care exclusively in one ICU during these hours. Rationale: The 4 hours per day, 7 days per week coverage will be an alternative to the historical 8 hours per day, 4 days per week coverage that has offered hospitals the opportunity for partial credit. Impact: Hospitals have greater flexibility in staffing structure to earn a score of “substantial progress” on the IPS standard. Please see page 48 of the survey reference book for detailed information on the IPS scoring algorithm.

21. 21 Section 6: NQF Safe Practices Change: At the end the Safe Practices section, hospitals are asked to provide information about the culture of safety instrument they are using Rationale: Since introducing the NQF Safe Practices to the Leapfrog Hospital Survey in 2004, Leapfrog has asked hospitals if they conduct a safety and quality survey of units using a nationally recognized tool. Given research that shows a link between performance on specific domains on culture of safety surveys and better patient outcomes, Leapfrog is interested in better understanding which tool hospitals are using to measure their culture of safety. Impact: Information that will be used to inform future survey questions. Responses to these extra questions will not be scored or publicly reported.

22. 22 Section 8 : Safety Focused Scheduling – OR Access Change: Added a set of questions that focuses on a patient’s access to the operating room by urgency level (i.e., urgent, emergent, scheduled) by surgical service. Reasoning: The goal of these new questions is to ensure that hospitals are achieving appropriate utilization rates without sacrificing patient access. Impact: These results will not be publicly reported until 2015. In 2014, hospitals will only be able to view their results for this measure on their password-protected “Details” page. In 2015, Leapfrog plans to publicly report individual hospital results on the OR Access section on the Leapfrog Hospital Survey Results website.

23. 23 Section 8 : OR Access Scoring Algorithm Fully meets the standard (4 filled bars): The hospital can document at least 75% of surgical subspecialties met their access targets 80% of the time for unscheduled cases, stratified by urgency level. Substantial Progress (3 filled bars): The hospital can document at least 50% of surgical subspecialties met their access targets 80% of the time for unscheduled cases, stratified by urgency level. Some Progress (2 filled bars): The hospital can document at least 25% of surgical subspecialties met their access targets 80% of the time for unscheduled cases, stratified by urgency level. Willing to Report (1 filled bar): The hospital can document less than 25% of surgical subspecialties met their access targets 80% of the time for unscheduled cases, stratified by urgency level. Does Not Apply: Hospitals that do not operate more than one operating room that services inpatients (Answered “No” to Smooth Patient Scheduling question #1). Response Not Required: Hospital reported that elective surgeries made up less than 10% of their total admissions (Answered “No” to Smooth Patient Scheduling question #2) and choose not to provide responses for the remaining questions. Declined to Respond: The hospital did not provide responses to this section OR answered ‘no’ to question #1 in this subsection OR answered ‘Choose Not to Report’ or ‘Can Not Measure’ to question #2 in this subsection.

24. 24 Section 9: Resource Utilization for Common Acute Conditions Change: In 2013, Leapfrog added a series of questions based on volume and readmission rates reported by CMS for three common acute conditions: AMI, Heart Failure, and Pneumonia. At that time, critical access hospitals were not able to access these questions in the online survey. In 2014, critical access hospitals that voluntarily reported 30-day risk standardized readmission rates for AMI, Heart Failure, and/or Pneumonia to CMS will be able to complete these questions on the online Leapfrog Hospital Survey. Critical access hospitals that do not voluntarily report this information to CMS will continue to be scored as “Does Not Apply.”

25. 25 Ensuring Data Integrity Leapfrog will continue to conduct reviews of hospital responses (find details at https://leapfroghospitalsurvey.org/web/wp- content/uploads/deskreview.pdf)https://leapfroghospitalsurvey.org/web/wp- content/uploads/deskreview.pdf Leapfrog continues to add high-visibility data licensees and release high-profile press campaigns (i.e. early elective deliveries) 2013 – Leapfrog had a random 1% of responding hospitals submit documentation for specific responses to provide greater assurance of data accuracy (e.g., hospitals asked to provide a copy of their Never Events policy and to document safe practice adherence)

26. 26 How Results are Displayed and Used

27. 27 How Results Are Displayed www.LeapfrogGroup.org/cp

28. How Results are Used Updated monthly (within the first 5 business days of the month) from July through February to reflect updates and new survey submissions Viewed by Leapfrog members and partners, as well as other employers, purchasers, and consumers Used to recognize high performance by Leapfrog, our members and Regional Roll- Outs, and by health plans (e.g. Top Hospitals and LHRP) Used by other statewide and national organizations, regional and national health plans, and publicly reported by other transparency vendors Used to calculate the Hospital Safety Score (www.HospitalSafetyScore.org)www.HospitalSafetyScore.org Used as a quality improvement tool and a benchmarking tool by hospitals 28

29. 29 Questions?