Transcription of Leapfrog Hospital Survey
1 Leapfrog Hospital Survey Hard Copy QUESTIONS & REPORTING PERIODS ENDNOTES MEASURE SPECIFICATIONS FAQS 2 Version First Release: April 1, 2017 Updated Release: June 2, 2017 Table of Contents Table of Contents Welcome to the 2017 Leapfrog Hospital 6 Important Notes about the 2017 Survey .. 6 Overview of the 2017 Leapfrog Hospital Survey .. 7 Pre-Submission Checklist .. 9 Instructions for Submitting a Leapfrog Hospital Survey .. 10 Helpful Tips for Verifying Submission .. 11 Tips for updating or correcting a previously submitted Leapfrog Hospital Survey .
2 11 Deadlines .. 13 Deadlines for the 2017 Leapfrog Hospital Survey .. 13 Deadlines to Join Leapfrog s NHSN Group .. 13 Deadlines Related to the Hospital Safety Grade .. 13 Technical 14 Help Desk .. 14 Leapfrog Survey Users Group .. 14 Reporting Periods .. 15 Page Intentionally Left Blank .. 17 PROFILE .. 18 Profile .. 19 Profile .. 20 Facility Information .. 20 Demographic Information .. 20 Contact Information .. 21 Page Intentionally Left Blank .. 23 SECTION 1: BASIC Hospital INFORMATION .. 24 Section 1: 2017 Basic Hospital Information .. 25 1: Basic Hospital Information .. 26 Section 1: 2017 Basic Hospital Reference Information.
3 28 What s New in the 2017 Survey .. 28 Change Summary since 28 Page Intentionally Left Blank .. 29 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 Information .. 34 What s New in the 2017 Survey .. 34 Change Summary since 34 3 Version First Release: April 1, 2017 Updated Release: June 2, 2017 Table of Contents CPOE Frequently Asked Questions (FAQs).
4 35 Page Intentionally Left Blank .. 36 SECTION 3: INPATIENT SURGERY .. 37 Section 3: 2017 Inpatient Surgery .. 38 3A: Hospital and Surgeon Volume .. 39 3B: Surgical Appropriateness .. 46 Section 3: 2017 Inpatient Surgery Reference Information .. 48 What s New in the 2017 Survey .. 48 Change Summary since 48 Inpatient Surgery Measure Specifications Hospital and Surgeon Volume .. 49 Carotid Endarterectomy Measure References .. 50 Mitral Valve Repair and Replacement Measure References .. 51 Open Aortic Aneurysm Repair Measure References .. 52 Lung Resection Measure References .. 53 Esophageal Resection Measure References.
5 55 Pancreatic Resection Measure References .. 56 Rectal Cancer Surgery Measure References .. 57 Hip Replacement Measure References .. 58 Knee Replacement Measure References .. 61 Bariatric Surgery for Weight Loss Measure References .. 62 Inpatient Surgery Frequently Asked Questions (FAQs) .. 64 Page Intentionally Left Blank .. 65 SECTION 4: MATERNITY CARE .. 66 Section 4: 2017 Maternity Care .. 67 4A Maternity Care Volume .. 68 4B: Elective 69 4C: Cesarean Birth .. 70 4D: Episiotomy .. 71 4E: Process Measures of Quality .. 72 4F:High-Risk Deliveries .. 73 High-Risk Deliveries .. 73 Neonatal Intensive Care Unit(s) Volume.
6 74 Neonatal Intensive Care Unit(s) National Performance Measurement .. 74 Process Measure of Quality Antenatal Steroids .. 75 Section 4: 2017 Maternity Care Reference Information .. 77 What s New in the 2017 Survey .. 77 Change Summary since 77 Maternity Care Measure Specifications .. 78 4 Version First Release: April 1, 2017 Updated Release: June 2, 2017 Table of Contents Maternity Care Volume .. 78 Elective Deliveries .. 79 Cesarean Birth .. 81 Episiotomy .. 83 Maternity Care Process Measure Specifications .. 84 Newborn Bilirubin Screening Prior to Discharge.
7 84 Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery .. 85 High-Risk Deliveries Measure Specifications .. 86 High-Risk Deliveries Volume Standard .. 86 VON National Performance Measure Specifications .. 87 Antenatal Steroids Process Measure .. 88 Page Intentionally Left Blank .. 90 SECTION 5: ICU PHYSICIAN STAFFING (IPS) .. 91 Section 5: 2017 ICU Physician Staffing (IPS) Standard .. 92 5: ICU PHYSICIAN STAFFING (IPS) .. 93 Section 5: 2017 ICU Physician Staffing (IPS) Reference 96 What s New in the 2017 Survey .. 96 Change Summary since 96 IPS Frequently Asked Questions (FAQs).. 97 General Questions .. 97 Certification Questions.
8 98 Response Time Questions .. 98 Page Intentionally Left Blank .. 100 SECTION 6: NQF Safe Practices .. 101 Section 6: 2017 NQF Safe Practices .. 102 6A: Practice #1 - Culture of Safety Leadership Structures and Systems .. 104 6B: Practice #2 - Culture Measurement, Feedback, and Intervention .. 106 6C: Practice #4 - Risks and Hazards .. 108 6D: Practice #9 - Nursing Workforce .. 110 6E: Practice #19 - Hand Hygiene .. 112 Section 6: 2017 NQF Safe Practices Reference Information .. 115 What s New in the 2017 Survey .. 115 Change Summary since 115 Tips for Reporting on Section 6 Safe Practices .. 116 Safe Practices Frequently Asked Questions (FAQs).
9 117 General FAQs for the Safe Practices: .. 117 FAQs Specific to Safe Practices .. 119 Page Intentionally Left Blank .. 125 5 Version First Release: April 1, 2017 Updated Release: June 2, 2017 Table of Contents SECTION 7: MANAGING SERIOUS ERRORS .. 126 Section 7: 2017 Managing Serious 127 7A: The Leapfrog Group Never Events Policy Statement .. 128 7B: Healthcare-Associated Infections .. 129 7C: Hospital -Acquired Conditions Pressure Ulcers and Injuries .. 130 7D: Antibiotic Stewardship Practices .. 131 Section 7: 2017 Managing Serious Errors Reference Information.
10 134 What s New in the 2017 Survey .. 134 Change Summary since 134 Never Events Frequently Asked Questions (FAQs) .. 135 Healthcare-Associated Infections Specifications .. 137 Pressure Ulcers and Injuries Measure Specifications .. 139 Page Intentionally Left Blank .. 140 SECTION 8: MEDICATION SAFETY .. 141 Section 8: 2017 Medication Safety .. 142 8A Bar Code Medication Administration .. 143 8B: Medication Reconciliation .. 145 Section 8: 2017 Medication Safety Reference Information .. 147 What s New in the 2017 Survey .. 147 Change Summary since 147 BCMA Frequently Asked Questions (FAQs) .. 148 Medication Reconciliation Measure Specifications.
