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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
Page Intentionally Left Blank17
PROFILE18
Profile19
Profile20
Facility Information20
Demographic Information20
Contact Information21
Page Intentionally Left Blank23
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
Page Intentionally Left Blank29
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
Page Intentionally Left Blank36
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
Page Intentionally Left Blank63
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
Page Intentionally Left Blank88
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
Page Intentionally Left Blank98
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
Page Intentionally Left Blank123
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
Page Intentionally Left Blank138
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
Page Intentionally Left Blank152
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