Measure Use of ICD 9 or ICD 10 codes Use of ICD 9 or ICD 10 codes Section 1 Basic Hospital Information 12-months ending 12/31/2015 N/A 12-months ending 06/30/2016 N/A Section 2 Computerized Prescriber Order Entry (CPOE) Latest 3-months prior to survey submission N/A Latest 3-months to survey submission N/A Section 3 Hospital Referral (AVR, AAA, Pancreatectomy, Esophagetcomy) 12-months or 24-months ending 09/30/2015 ICD-9 12-months or 24-months ending 09/30/2015 ICD-9 4A Maternity Care 9-months ending 09/30/2015 N/A 9-months ending 06/30/2016 N/A 4B Early Elective Deliveries 9-months ending 09/30/2015 ICD-9 9-months ending 06/30/2016 ICD-10 4C NTSV Cesarean Section 9-months ending 09/30/2015 ICD-9 9-months ending 06/30/2016 ICD-10 4D Incidence of Episiotomy 9-months ending 09/30/2015 ICD-9 9-months ending 06/30/2016 ICD-10 4E Bilirubin Screening & DVT Prophylaxis 9-months ending 09/30/2015 N/A 9-months ending 06/30/2016 N/A 4F High-Risk Newborn Deliveries Volume: 12-months ending 09/30/2015 ICD-9 Volume: 12-months ending 09/30/2015 ICD-9 VON: Latest 12- or report N/A VON: Latest 12- or report N/A Antenatal Steroids: 9-months ending 09/30/2015 ICD-9 Antenatal Steroids: 9-months ending 06/30/2016 ICD-10 5 ICU Physician Staffing Latest 3-months prior to survey submission N/A Latest 3-months to survey submission N/A 6 National Quality Forum’s Safe Practices Latest 12- or 24-months prior to submission (see individual safe practice for specific reporting period) N/A Latest 12- or 24-months prior to submission (see individual safe practice for specific reporting period) N/A 7A Never Events Policy N/A N/A N/A N/A
7B CLABSI and CAUTI (ICU only) 12-months ending 12/31/2015 N/A 12-months ending 06/30/2016 N/A 7C Surgical Site Infection: Major Colon Surgery, MRSA, and C. Diff. 12-months ending 12/31/2015 N/A 12-months ending 06/30/2016 N/A 7D Hospital-acquired Injuries and Pressure Ulcers 9-months ending 09/30/2015 ICD-9 9-months ending 06/30/2016 ICD-10 7E Antibiotic Stewardship Programs N/A N/A N/A N/A 8 Bar Code Medication Administration Latest 3-months prior to survey submission N/A Latest 3-months prior to survey submission N/A 9 Readmission for Common Acute Conditions & Procedures N/A N/A N/A N/A Page Intentionally Left
Email Address System Contact Email Address Additional Contact Information Please provide the email address for your hospital’s general inbox (e.g. ). This will be used on the Leapfrog Hospital Results website for patients and consumers to provide feedback directly to your hospitals.
Page Intentionally Left Blank SECTION 5: ICU PHYSICIAN STAFFING (IPS) This section includes questions and reference information for Section 5 ICU Physician Staffing. Please carefully review the questions, endnotes, and reference information (e.g., measure specifications, notes, and frequently asked questions) before you begin. Failure to review the reference information could result in inaccurate responses. Section 5: 2016 ICU Physician Staffing (IPS) Standard Link to IPS Fact A hospital fully meeting this standard assures that: in its are by physicians who: Are (on-site, or via 33 that meets Leapfrog specifications) during daytime hours a minimum of 8 hours per day, 7 days per week, and during this time provide clinical care 30 in the ICU; and At other times** . . . ; Return more than 95% of ICU calls/pages within 5 minutes, based on a of notification device response time;* and Can rely on a physician, physician assistant, nurse practitioner, or a who is in the hospital and able to reach ICU patients within 5 minutes in more than 95% of cases, based on a quantified hospital analysis of notification device response time.* * This may exclude low-urgency calls/pages, if the notification device system can designate low-urgency calls/pages or if the hospital has an alternative scientific method for documenting high-urgency calls/pages that are not returned within 5 minutes.
Has your hospital measured its incidence of Central Line-Associated Bloodstream Infections (CLABSI) in an intensive care unit for the Reporting Time Period using definitions and measure specifications developed by the CDC’s National Healthcare Safety Network (NHSN) and chosen to report this information to the survey? If “no,” CLABSI score will show as “Declined to Respond.” If your hospital did not use the NHSN definitions and measure specifications, you must respond “no” to this question. If “yes, but did not have any central line days during the reporting period,” CLABSI score will show as “Does Not Apply.” Yes No Yes, but did not have any central line days during the reporting period Has your hospital measured its incidence of Catheter-Associated Urinary Tract Infections (CAUTI) in an intensive care unit for the Reporting Time Period using definitions and measure specifications developed by the CDC’s National Healthcare Safety Network (NHSN) and chosen to report this information to the survey? If “no,” CAUTI score will show as “Declined to Respond.” If your hospital did not use the NHSN definitions and measure specifications, you must respond “no” to this question. If “yes, but did not have any catheter days during the reporting period,” CAUTI score will show as “Does Not Apply.” Yes No Yes, but did not have any catheter days during the reporting period Has your hospital reported this information (referred to in question #3 and #4) to the CDC/NHSN? Continue with question #6 regardless. Yes No Is your hospital designated as a “”? Continue with questions #7 regardless. Yes No Does your hospital utilize personnel trained in ? Yes No Check all ICU types that were staffed and open during the reporting period: Medical Surgical Medical/Surgical Pediatric Medical Pediatric Medical/Surgical Pediatric Cardiothoracic Medical Cardiac Respiratory Surgical Cardiothoracic Neurologic Neurosurgical Burn Trauma NICU II/III NICU III Total number of central line days and central line-associated bloodstream infections in each ICU type during the reporting period as reported to the CDC/NHSN:
Specifications: Hospitals that share a Medicare Provider Number are required to report by facility. Please carefully review . Reporting Time Period: Answer questions #1-12 for the latest 3 month period prior to the submission of this section of the survey. What is the latest 3-month reporting period for which your hospital is submitting responses to this section? 3-month reporting time period ending: ______ Format: MM/YYYY Does your hospital use a Bar Code Medication Administration (BCMA) system that is linked to the electronic medication administration record (eMAR) when administering medications at the bedside in at least one inpatient unit? If “yes,” complete questions #3-12. If “no,” skip to the affirmation. Yes No Does your hospital operate Intensive Care Units (adult, pediatric, and/or neonatal)? If “no,” skip questions #4 and #5. Yes No If “yes,” how many of this type of unit are open and staffed in the hospital? _____ How many of the in question #4 utilized the BCMA/eMAR system when administering medications at the bedside? Does your hospital operate Medical and/or Surgical Units? If “no,” skip questions #7 and #8. Yes No If “yes,” how many of this type of unit were open and staffed in the hospital? _____ How many of the units in question #7 utilized the BCMA/eMAR system when administering medications at the bedside? _____ If “no,” to questions #3 AND #6, skip the remainder of the questions and go to the affirmation. Your hospital will be scored as “Does Not Otherwise, move on to questions #9-12. The number of inpatient medication administrations ordered and scannable during the reporting period in those units indicated in questions #3-8 above? _____