Section 3: 2018 Inpatient Surgery Inpatient Surgery Fact This section is not applicable to Pediatric hospitals. Section 3 includes questions about your hospital and surgeon volume for eight high-risk procedures and surgical appropriateness criteria to prevent unnecessary procedures. Each hospital fully meeting this standard for each of the eight applicable surgical procedures: Meets the minimum hospital volume standard for the surgical procedure Has a process for privileging surgeons that includes the surgeon meeting or exceeding the minimum surgeon volume standard for the surgical procedure Additionally, when visitors to Leapfrog’s public reporting website into the score icon (i.e. four filled bars, three filled bars, etc.) indicating the performance category for the surgery, they will see a statement indicating whether the hospital has processes and protocols in place to ensure surgical appropriateness. Hospitals that respond “Yes” to all five questions specific to that surgery will be reported as “Yes” and hospitals that respond “No” to any one of the five questions will be reported as “Not Yet.” Download the 2018 Leapfrog Hospital Survey Scoring Algorithm on the . 3A: Hospital and Surgeon Volume Specifications: See in the Inpatient Surgery Reference Information on page 48. Hospitals that share a Medicare Provider Number are required to report by facility. Please carefully review . 12-month or 24-month reporting time period used: 01/01/2017 – 12/31/2017 (12-month count) 01/01/2016 – 12/31/2017 (24-month annual average) 07/01/2017 – 06/30/2018 (12-month count) 07/01/2016 – 06/30/2018 (24-month annual average)
engaging nursing leadership at the unit level on BCMA use. Additionally, information from these structures is used to implement quality improvement projects or monitor previous quality improvement projects focusing on the hospital’s BCMA system. Results from the quality improvement projects are evaluated and demonstrate that these projects have resulted in higher adherence to standard medication administration processes. Finally, resolution of system deficiencies and/or problems that may have contributed to the workaround are communicated back to the end user. Each hospital meeting the Medication Reconciliation standard: Has a protocol in to collect data on the accuracy of the hospital’s medication reconciliation process. Has no potential data errors. Download the 2018 Leapfrog Hospital Survey Scoring Algorithm on the . 8A Bar Code Medication Administration Hospitals that a Medicare Provider Number are required to report by facility. Please carefully review . Reporting Time Period: 3 months Answer questions #1-15 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 #3-15. If “no,” skip the remaining questions in 8A and move on to the next subsection. 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 (adult and/or pediatric)? If “no,” skip questions #7 and #8. Yes No