Abdominal Aortic Aneurysm (AAA) Repair – Volume Specifications: See in the EBHR Reference Information on page 47. Reporting time period used was 12- or 24-months: 10/01/2014 – 09/30/2015 10/01/2013 – 09/30/2015 Total number of patients (including those that expired) with an AAA Repair procedure at this hospital location. Annual number of patients for the volume Reporting Time Period (or annual average if reporting on 24 months of data) _______ Total number of patients (including those that expired) with an unruptured AAA Repair procedure at this hospital location Annual number of patients for the volume Reporting Time Period (or annual average if reporting on 24 months of data) _______ How many patients included in question #3 died in the hospital following this procedure? (More information)15 (Annual average if reporting on 24 months of data) _______ 3D: Pancreatic Resections If you answered 'yes' to question #3 in Section 3A, indicating that you perform Pancreatic Resection, complete questions pertaining to this high-risk surgery. Pancreatic Resections – Volume Specifications: See in the EBHR Reference Information on pages 48-49. Reporting time period used was 12- or 24-months: 10/01/2014 – 09/30/2015 10/01/2013 – 09/30/2015 Total number of patients (including those that expired) with a Pancreatic Resection procedure at this hospital location. _______
reporting time period used: 01/01/2015 - 09/30/2015 10/01/2015 - 06/30/2016 Total number of vaginal deliveries during the reporting period with Excluded Populations removed. ______ Total number of mothers indicated in question #2 that had an episiotomy procedure performed. ______ 4E: Process Measures of Quality Specifications: See in the Maternity Care Reference Information on pages 70-71. Sufficient Sample: See for instructions for identifying a sufficient sample to answer questions #3-4 and #8-9. Newborn Bilirubin Screening to Discharge 9-month reporting time period used: 01/01/2015 - 09/30/2015 10/01/2015 - 06/30/2016 Has your hospital performed a medical record audit on all cases (or a sufficient sample of them) for the Reporting Time Period and measured adherence to the newborn bilirubin screening prior to discharge clinical guideline? If “yes,” but fewer than 10 cases met the inclusion criteria for the denominator, skip questions #3-5. Yes No Yes, but fewer than 10 cases met the inclusion criteria for the denominator Number of cases measured against the guideline, either all cases or a sufficient sample of them (denominator) ______ Number of in question #3 that adhere to the clinical process guideline (numerator) ______ Do the responses in questions #3 and #4 represent a sample of cases? Yes No Appropriate DVT Prophylaxis in Undergoing Cesarean Section reporting time period used: 01/01/2015 - 09/30/2015 10/01/2015 - 06/30/2016 Has your hospital performed a medical record audit on all cases (or a sufficient sample of them) for the Reporting Time Period and measured adherence to the appropriate DVT prophylaxis in women undergoing cesarean section clinical guideline? Yes No Yes, but fewer than 10 cases met the inclusion criteria for the denominator
Page Intentionally Left Blank SECTION 7: MANAGING SERIOUS ERRORS This section includes questions and reference information for Section 7 Managing Serious Errors. 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 7: 2016 Managing Serious Errors Link to Never Events Fact Sheet: This section of the survey addresses the occurrence of serious errors in hospitals. Hospitals are asked to implement the five principles of Leapfrog’s Never Events policy when a serious error or “never event” occurs within their facility. More information on the five principles of the policy is available at: .
Total number of central line days (denominator) Total number of central bloodstream infections (numerator) Medical Surgical Medical/Surgical Pediatric Medical Pediatric Medical/Surgical Pediatric Cardiothoracic Medical Cardiac Respiratory Surgical Cardiothoracic Neurologic Neurosurgical Burn Trauma NICU II/III <= 750 g 751 – 1,000 g 1,001 – 1,500 g 1,501 – 2,500 g >2,500 g NICU III <= 750 g 751 – 1,000 g 1,001 – 1,500 g 1,501 – 2,500 g >2,500 g Total number of urinary catheter days and catheter-associated urinary tract infections in each ICU type during the reporting period as reported to the CDC/NHSN: 10a) Total number of catheter days: (denominator) 10b) Total number of urinary tract infections: (numerator) Medical Surgical Medical/Surgical Pediatric Medical Pediatric Medical/Surgical Pediatric Cardiothoracic Medical Cardiac Respiratory Surgical Cardiothoracic Neurologic Neurosurgical Burn Trauma
specific details of what constitutes “waiving cost” should be handled on a case-by-case basis by the parties involved. CLABSI and CAUTI Specifications Important Note: Hospitals that share a Medicare Provider Number are required to report by facility. Please carefully review . Incidence Rate of Central Line-Associated Bloodstream Infections Source: National Quality (NQF) #0139 Rates will be stratified by ICU type – medical, surgical, medical/surgical, pediatric medical, pediatric medical/surgical, pediatric cardiothoracic, medical cardiac, respiratory, surgical cardiothoracic, neurologic, neurosurgical, burn, trauma, Level II/III NICU, and Level III NICU, (see below for a table of ICU types). Reporting Time Period: 12 months Surveys submitted prior to September 1, 2016: 01/01/2015 – 12/30/2015 Surveys (re)submitted on or September 1, 2016: 07/01/2015 – 06/30/2016
The number of medication administrations from question #9 that had both the patient and the medication scanned during administration with a BCMA system that is linked to the electronic medication administration record (eMAR)? _____ What types of decision support does your hospital’s BCMA system provide to users of the system? (Do not any questions blank) a) Wrong patient Yes No b) Wrong medication Yes No c) dose Yes No d) time (e.g., early/late warning; warning that medication cannot be administered twice within a given window of time) Yes No e) Vital sign check Yes No f) Patient-specific allergy check Yes No g) Second nurse check needed Yes No Which of the following mechanisms does your hospital use to reduce and understand potential BCMA system “workarounds”? (Do not leave any questions blank) a) Has a formal committee that meets routinely to review data reports on BCMA system use Yes No b) Has back-up systems for hardware failures Yes No c) Has a Help Desk that provides timely responses to urgent BCMA issues in real-time Yes No d) Conducts real-time observations of users using the BCMA system Yes No e) Engages nursing leadership at the unit on BCMA use Yes No Affirmation of Accuracy: As the hospital CEO or as an employee of the hospital to whom the hospital CEO has delegated responsibility, I have reviewed this information pertaining to the Bar Code Medication Administration Section at our hospital, and I hereby certify that this information is true, accurate, and reflect the current, normal operating circumstances at our hospital. I am authorized to make this certification on behalf of our hospital.