1. 1 © 2004 TMIT TMIT The Leapfrog NQF Safe Practices Briefing Carol Ferguson, RN, MSN Director of Patient Safety and Performance Improvement Texas Medical Institute of Technology Patient Safety Officers College September 15, 2004

2. 2 © 2004 TMIT TMIT The Leapfrog NQF Safe Practices Submitter’s Briefing Background NQF Safe Practices Survey Scoring Algorithm for NQF SP Submitter’s Toolbox: Five Stages AssessCollectSubmitPlanPrepare

3. 3 © 2004 TMIT TMIT The Leapfrog NQF Safe Practices Submitter’s Briefing Background NQF Safe Practices Survey Scoring Algorithm for NQF SP Submitter’s Toolbox: Five Stages AssessCollectSubmitPlanPrepare

4. 4 © 2004 TMIT TMIT What is Leapfrog? More than 150 large health care purchasers Founded in 2000 More than $62 billion in health care expenditures More than 34 million Americans

5. 5 © 2004 TMIT TMIT Leapfrog Mission Trigger giant leaps forward in the safety, quality and affordability of health care Informed health care decisions - Surveys High-value health care through P-4-P Programs 24 “Roll-Out” Regions to arrive at aggressive but feasible targets

6. 6 © 2004 TMIT TMIT 24 “Roll-Out” Regions

7. 7 © 2004 TMIT TMIT What is the National Quality Forum (NQF)? The NQF, a non-profit voluntary consensus standards setting organization Membership represent both Public and Private sectors

8. 8 © 2004 TMIT TMIT NQF Member Organizations NPSF

9. 9 © 2004 TMIT TMIT Safe Practice Background “National Quality Forum Safe Practices for Better Healthcare: A Consensus Report” was developed to help standardize evidence based safe practices of care. The Leapfrog NQF Safe Practices ‘Leap’ is using these safe practices to survey hospital performance

10. 10 © 2004 TMIT TMIT NQF Safe Practices for Better Healthcare: A Consensus Report 30 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness

11. 11 © 2004 TMIT TMIT The Leapfrog NQF Safe Practices Submitter’s Briefing Background NQF Safe Practices Survey Scoring Algorithm for NQF SP Submitter’s Toolbox: Five Stages AssessCollectSubmitPlanPrepare

12. 12 © 2004 TMIT TMIT The Leapfrog NQF Safe Practices ‘Leap #4’ NQF- endorsed 30 high-priority Safe Practices to be universally applied in relevant clinical care settings Includes Leapfrog’s initial 3 safe practices Leapfrog will now assess hospitals’ progress on the remaining 27 safe practices

13. 13 © 2004 TMIT TMIT www.leapfroggroup.org Click Here

14. 14 © 2004 TMIT TMIT Click Here

15. 15 © 2004 TMIT TMIT

16. 16 © 2004 TMIT TMIT Development of this New Survey Survey Tool developed by Texas Medical Institute of Technology (TMIT) 27 practices weighted according to patient safety impact, combined into a single score (1,000) Relative ranking compared to other hospitals - placed into quartiles First Public Results to be released in mid-July 2004

17. 17 © 2004 TMIT TMIT The Leapfrog NQF Safe Practices Submitter’s Briefing Background NQF Safe Practices Survey Scoring Algorithm for NQF SP Submitter’s Toolbox: Five Stages AssessCollectSubmitPlanPrepare

18. 18 © 2004 TMIT TMIT Go to Page 95

19. 19 © 2004 TMIT TMIT

20. 20 © 2004 TMIT TMIT The Leapfrog NQF Safe Practices Submitter’s Briefing Background NQF Safe Practices Survey Scoring Algorithm for NQF SP Submitter’s Toolbox: Five Stages AssessCollectSubmitPlanPrepare

21. 21 © 2004 TMIT TMIT Click Here to Obtain Submitter’s Checklist

22. 22 © 2004 TMIT TMIT AssessCollectSubmitPlan Prepare Stage 1: Prepare Obtain hard copy or digital PDF version of the NQF Safe Practices for Better Health Care: A Consensus Report Print a hard copy of the Leapfrog survey and Frequently Asked Questions (FAQs) Organize Survey Submission team

23. 23 © 2004 TMIT TMIT Click Here for NQF Report Order Form

24. 24 © 2004 TMIT TMIT

25. 25 © 2004 TMIT TMIT www.safetyleaders.org/nqfsp Click Here to Buy PDF

26. 26 © 2004 TMIT TMIT Click Here to Download FAQs Click Here to Download survey

27. 27 © 2004 TMIT TMIT AssessCollectSubmit Prepare Stage 2: Plan Pull a team of “internal experts” together to help answer the survey Including: 1.Nursing 2.Pharmacy 3.Infection Control 4.Surgical Services 5.Administration Assign team member responsibilities for individual survey questions Develop Survey Submission Plan Plan

28. 28 © 2004 TMIT TMIT AssessSubmit Prepare Stage 3: Collect Each team member collects source documents to support survey question answers Inventory source documents to each Safe Practice; establish a filing system as resource for gap analysis and future survey submissions Perform gap analysis to determine what documents are missing that need to support remaining survey questions Plan Collect

29. 29 © 2004 TMIT TMIT Submit Prepare Stage 4: Assess Create a draft survey to determine baseline score Identify pre-submission actions that can be immediately implemented to finalize an answer to any survey questions. Identify Commitment answers to survey questions to optimize survey score Prepare potential Commitment Scenarios (see example) Plan Collect Assess

30. 30 © 2004 TMIT TMIT Example Commitment Scenario Baseline Score: No Commitments: 375 points Add Potential Commitments: Establish direct and regular briefings of our trustees/board of directors by a Patient Safety Officer Publicly disclose implementation of (or compliance with) NQF safe practices applicable to the organization. Dedicated line item budget allocation to various specific patient safety practices Potential Optimized Score:525 points

31. 31 © 2004 TMIT TMIT Prepare Stage 5: Submit Final CEO Briefing Review baseline survey score Make decisions regarding immediate pre-submission actions Present optimized score with commitments Give recommendations for Performance Improvement Projects Plan Collect Assess Submit

32. 32 © 2004 TMIT TMIT Prepare Stage 5: Submit (Continued) Submit to Leapfrog Web Site: www.leapfrog.medstat.com www.leapfrog.medstat.com Obtain CEO agreement to certify submission Acquire a Security Code from the Leapfrog Web Site Create Follow-up Action Plan Plan Collect Assess Submit

33. 33 © 2004 TMIT TMIT Click Here to Obtain Security Code Click Here to Submit Survey

34. 34 © 2004 TMIT TMIT