Additional Information about the leap is available there as ...

Data collection, analysis, and support services provided by Medstat.

2007 Evidence-Based Hospital Referral (EHR) Leap

Each hospital fulfilling one or more of these Leaps:

1. Achieves one or more of these favorable hospital volume characteristics:

Treatments(See specifications below) Favorable Volume Characteristics3, 4

Coronary artery bypass graft1 450 or more total procedures/year for the hospital 90% of total procedures by surgeons meeting

surgeon-volume threshold of 100/year in one or more facility

Percutaneous coronary intervention2 400 or more total procedures/year for the hospital 90% of total procedures by surgeons meeting


Aortic valve replacement 120 or more total procedures/year for the hospital

90% of total procedures by surgeons meeting surgeon-volume threshold of 22/year in one or more facility

Abdominal aortic aneurysm repair 50 or more total procedures/year for the hospital 90% of total procedures by surgeons meeting


Pancreatic resection 11 or more total procedures/year for the hospital 90% of total procedures by surgeons meeting


Esophagectomy 13 or more total procedures/year for the hospital 90% of total procedures by surgeons meeting


Bariatric surgery 100 or more total procedures/year for the hospital All procedures by surgeons meeting surgeon-

volume threshold of 20/year in one or more facilityHigh-risk deliveries: Delivery with gestational age <32 weeks

or expected birth weight <1500 grams Delivery with prenatal diagnosis of major

congenital anomalies

Average daily neonatal ICU census > 15 for all babies regardless of diagnosis

1 Except hospitals in CA, NJ, NY and PA with adequate publicly-reported sample sizes (see additional information on publicly reported performance information above).

2 Except hospitals in NY with adequate publicly-reported sample sizes (see additional information on publicly reported performance information above).

3 Annual total volume for hospital is calculated for most recent 12 months available or as annual average over most recent 24 months available, for a period ending within the last year.

4 Surgeon volume is determined based on either: volume by surgeon at this hospital based on the total reported hospital procedures for the time period reported; or, if available

October 19, 2006 v4.0a 2007 Survey DRAFT


for each surgeon accounting for any of the hospital’s total reported procedure volume, the annual volume for that surgeon at all facilities in which s/he operates. An average annual rate for as many as three recent consecutive years may be used, as long as the time period ends no longer than 18 months prior to the hospital’s survey submission.

But in either case, the total reported procedure volume at that hospital by those surgeons is used to determine whether the 90% threshold is met, NOT including any procedures done elsewhere by those surgeons.

and

2. For coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), aortic valve replacement (AVR), and bariatric surgery: Participates in and scores better than the national average for participating U.S. hospitals in its ratio of observed-to-expected mortality in the procedure-specific measurement systems operated by the Society of Thoracic Surgeons (STS), the American College of Cardiology (ACC), or the American College of Surgeons (ACS). For more information, see:

STS-Adult Cardiac Care: www.sts.orgACC-NCDR™: www.accncdr.com/WebNCDR/Common ACS-NSQIP: acsnsqip.org

Partial credit is alternatively provided, for CABG, PCI, AVR, abdominal aortic aneurysm repair (AAA), or high-risk deliveries for 80% or higher adherence to nationally endorsed procedure-specific process measures of quality (See the Nationally Endorsed Procedure-Specific Process Measures of Quality, available on the home page of the online survey).

When a hospital’s performance is publicly reported via scientifically rigorous,1 audited, comparable and commonly utilized statewide performance assessment systems endorsed by The Leapfrog Group, fulfillment of the leap may be defined by favorable performance on statewide performance rather than criteria 1 and 2 above, if a hospital’s sample sizes are sufficient to produce a statistically stable result. Favorable performance is defined as ranking in the most favorable quartile for risk-adjusted mortality or observed-to-expected mortality, or in the second quartile and adhering to the Nationally Endorsed Procedure-Specific Process Measures of Quality as above.

Thus far, The Leapfrog Group has endorsed statewide performance assessment systems for CABG mortality in CA, NJ, NY, and PA, and for PCI in NY. To qualify for assessment by statewide performance instead of volume and the additional measures indicated above, a hospital’s results must be based on at least 350 CABGs or 400 PCIs as reported in its state’s most recent publicly-reported results.For hospitals that do not perform these procedures or treat these high-risk deliveries, or refer/transfer all safely and legally transferable patients for such high-risk procedures or conditions, the leap does not apply for that procedure or condition. If you answer ‘No’ to any of the procedures listed in questions 1-5 below, the notation ‘N/A’ will be displayed on the public Web site.

On the home page of the online survey, see links to: Medical Coding for High-Risk Procedures and Conditions for ICD-9 coding specifications

to identify and count the procedures or conditions identified above, and Process Measures of Quality for specification of the NQF-endorsed procedure-specific

process measures of quality

1 Scientifically Rigorous, Audited, and Comparable Performance Assessment Systems“Scientifically rigorous” indicates a measurement reporting system in which 1) all cases are reported; 2) there is a third party audit to affirm accuracy of submitted clinical data; 3) there is supplementary collection of clinical variables present upon admission that, when combined with routinely collected administrative data, predict a large portion of inter-hospital mortality differences; 4) data cover at least a 12-month period; and, 5) sample sizes per hospital are adequate to achieve statistically stable results.


https://acsnsqip.org/

http://www.accncdr.com/WebNCDR/Common

http://www.sts.org/


Additional Information about the leap is available there as well.


2007 Evidence-Based Hospital Referral Leap

High-Risk Surgical Procedures Provided

Does your hospital perform these procedures on an elective basis2?1) Coronary artery bypass graft Yes

No2) Percutaneous coronary intervention Yes

No3) Aortic valve replacement Yes

No4) Abdominal aortic aneurysm repair Yes

No5) Pancreatic resection Yes

No6) Esophagectomy Yes

No7) Bariatric surgery (for 2+ years3) Yes

No

On the home page of the online survey, see links to Medical Coding for High-Risk Procedures and Conditions for ICD-9 coding specifications and other criteria to identify and count these procedures.

If you answered yes to any questions #1-7 above, indicate the time period for which you are reporting volumes for these procedures. The same time period must be used to report all surgery volumes in subsequent EBHR sections8) Time period covered by

these datao 12-months ending:o 24-months ending:

MMYYYY e.g. 092006(period must end within the last year)

Note to reviewers: Online survey navigation will ask respondents first to complete questions 1 – 8. Based on those responses, users will be asked to complete separate Web pages for each EBHR procedure or condition which applies, one procedure or condition at a time, and save work after finishing each procedure or condition and between sessions.

2 High-risk Procedures Performed on an Elective BasisIf your hospital does not perform the procedure or ONLY does so when a patient is too unstable for safe transfer, answer ‘No’.

3 Bariatric Surgery Performed on an Elective Basis for 2+ YearsIf your hospital does not perform these procedures or has not been performing them for at least 24 months prior to the submission date of this survey, answer ‘No’.



2A: Coronary Artery Bypass Graft (CABG)If you answered Yes to #1 above, complete these sections pertaining to this high-risk surgery.

Coronary Artery Bypass Graft (CABG) – Volume

Answer questions #9-12 for the time period indicated in question #8.9) Total annual procedure volume at this hospital location

Annual number of procedures for the volume reporting period (annual average if 24 months of data)

_______

10) How many patients counted in question 9 died within 30 days post-operatively?4

(annual average if 24 months of data)_______

11) Number of surgeons performing5 more than 100 procedures annually at this hospital location for this time period _______

12) Number of procedures reported in question 9 that were performed by those surgeons included in question 11. _______

Some hospitals collect data, either from public data reporting or internal credentialing, measuring surgeon-specific volume for this procedure at all faclities. Indicate in question 13 if this is so for this hospital; if Yes, continue with questions 14–16.13) Do you know surgeon-specific volume for this procedure at all facilities,

including this hospital location?If No, skip questions 14–16.

YesNo

14) Period-ending of surgeon-specific volume data at all facilities:This may be a one- to three-year period, ending not more than 18 months prior to survey submission.

__________MMYYYYe.g. 122005

15) Number of surgeons performing Error: Reference source not found any of the procedures included in question 9 who performed at least 100 procedures annually at all facilities, including this hospital location

_______

16) Number of procedures reported in question 9 that were performed by those surgeons included in question 15. _______

4 Operating MortalityInclude intra-operative deaths as well as deaths within 30 days following surgery, whether in-hospital or not. This is consistent with “Operating Mortality” as used in the national performance measurement systems -- STS, ACC, ACS.

5 Surgeons Performing High-Risk ProceduresWhen determining surgeon-specific volume for a high-risk procedure, count the surgeries for the primary surgeon in charge. Do not attribute the surgery to any other surgeon, including those present but assisting in the operation.



Coronary Artery Bypass Graft (CABG) – Publicly Reported OutcomesHospitals in California, New Jersey, New York and Pennsylvania ONLY.All other hospitals, skip questions #17-20.

Follow instructions in Publicly Reported Outcomes for Coronary Procedures link on the home page of the online survey when responding to questions #17-20.17) Are CABG mortality outcomes for your hospital included in your state-

sponsored public outcomes report for the most recently reported period6? If no, skip to Question 21.

YesNo

18) If CABG mortality outcome results for your hospital are includedwith another hospital and/or publicly reported under a different hospitalname from that indicated in the Organization Information sectionof this survey, indicate the publicly-reported name of the hospital:

19) Does this most recent state-sponsored outcomes report show that your hospital’s most recently publicly-reported results are based on at least 350 CABGs?If no, skip to Question 21.

YesNo



20) Indicate the quartile ranking of your hospital’s risk-adjusted CABG mortality or ratio of observed to expected CABG mortality, as reported publicly by your state. (More Information7)

Most Favorable 25%Next 25% (2nd quartile)Next 25% (3rd quartile)Next 25% (4th quartile)

Coronary Artery Bypass Graft (CABG) – National Performance MeasurementIf your hospital is in NJ, NY, or PA and you answered questions #17 and #19 both “Yes”, skip questions #21-24.

Indicate your hospital’s participation in and results from the following national performance measurement system.21) Has your hospital participated in the Society of Thoracic Surgeons (STS)

performance reporting system for coronary artery bypass graft surgery and submitted data for all such procedures in the most recent 12-month period for which performance reports have been released? More Information8

If Yes, continue with questions #22-24; otherwise, skip to question 25.

YesNoParticipating but no reports yet available

22) What is the most recent 12-month reporting period for which STS performance results are available? 12 months ending: __________

MMYYYYe.g. 122005

23) From the report for that time period, what was the actual mortality rate9 as a percentage for coronary artery bypass graft surgery?Enter as percent with two decimal-place precision.

_______%

(e.g. 3.14)

Prefer not to respond24) From the same report, what was the risk-adjusted expected mortality

rate10 as a percentage for coronary artery bypass graft surgery?Enter as percent with two decimal-place precision.

_______%

(e.g. 4.23)

Prefer not to respond



Coronary Artery Bypass Graft (CABG) – Process Measures of QualityIf you answered question #1 “No”, skip this section.

Indicate your hospital’s adherence to nationally endorsed procedure-specific process measures of quality specific to this procedure, if measured. (see Process Measures link on survey home page)

You need only measure and report two of the eight indicators. You may measure and report on more than two, in which case survey results will be scored based on the two with the highest adherence rate.

Instructions For each of the eight guidelines, indicate:

(a) whether your hospital has performed a medical record audit on all cases (or a sufficient sample of them)11 for coronary artery bypass graft surgery over at least a 12-month period, but excluding cases admitted more than 24 months ago, and measured adherence to the Leapfrog expert panel-endorsed clinical process guideline for this procedure.*If no, skip (b) and (c) for this procedure.

(b) the number of cases measured against the guideline, either all cases or the sample size, for this procedure i.e., number of cases audited and meeting the criteria for inclusion in the denominator of the measure.

(c) The number of cases in (b) that adhere to the Leapfrog expert panel-endorsed clinical process guideline for this procedure (numerator).

* Responses may be based on the same data reported to JCAHO for National Hospital Quality Measures where those data are recent and consistent12 with these Nationally Endorsed Process Measures. Otherwise, hospitals can measure and report results as described here and in the Process Measures specifications (see link on home page).

Guideline (a)

Measured?if No,

skip (b) and (c)

(b)# Cases

Measured(denominator)

( c)# Cases Adhere

(numerator)25) Aspirin prescribed at discharge

(CABG-1)YesNo ______ ______

26) IMA grafting for isolated primary CABG (CABG-2)

YesNo ______ ______

27) Beta-blocker within 24 hours after surgery (CABG-3)

YesNo ______ ______

28) Beta-blockers prescribed at discharge (CABG-4)

YesNo ______ ______

29) Lipid-lowering therapy at discharge (CABG-5)

YesNo ______ ______

11 All Cases or a Sufficient SampleIf you have fewer than 60 cases that meet the criteria for inclusion in the denominator of the process measure, include ALL of these cases in measuring adherence to the process indicators. You should report results for cases from at least a 12-month period (unless your hospital only recently started offering these services, in which case for the time period that you have offered those services.) You need NOT use more than 12 months of historical experience to increase the eligible cases beyond 60; just measure and report based on ALL eligible cases that you have in that period.

If you have more than 60 cases that meet those criteria during the time period of the audit, you may randomly sample 60 of them for the denominator of each indicator, and measure and report adherence based on that sample. When sampling from a larger population of cases, this is the minimum number of cases needed to make a statistically reliable statement of percentage adherence to the process guideline.



30) Appropriate selection of antibiotic prophylaxis (CABG-7)

YesNo ______ ______

31) Antibiotic prophylaxis within 1 hour pre-op (CABG-8)

YesNo ______ ______

32) Discontinue antibiotic prophylaxis <24 hrs post-op (CABG-9)

YesNo ______ ______

12 Process Measures: Recent and Consistent Data Reported to JCAHOMany of the Process Measures of Quality used in this survey are consistent with Nationally Endorsed Process Measurement systems, e.g., the JCAHO National Hospital Quality Measures set. Hospitals that submit data to JCAHO for those measures may use the same data to respond to the Leapfrog survey questions for that same measure.

To use those data as the basis for responding to the Leapfrog Process Measures questions,

The data must have been reported and accepted by JCAHO. Responses in the survey must be based on the aggregate of a consecutive four quarters of data,

for a period ending not more than 12 months prior to submission of the survey. The data and results for a measure must be consistent with the Leapfrog specifications for that

same measure. (Because JCAHO modifies its measures and specifications periodically, please verify that the measures are defined consistently with the Leapfrog specifications for all four quarters of JCAHO data.) See the Process Measures specifications (link on the survey home page) for specifications as well as information about which JCAHO measures correspond to the Leapfrog Process Measures.

6 Most Recently Available Coronary Artery Surgery Mortality Results in Publicly Reporting StatesAs of March 1, 2006, the most recent publicly-reported results are for: California: 2002 (report dated Feb 2005) – Your answers should be based on 2002 discharges, if at

least 350 cases were reported for that year by your hospital in the 2000-02 report. Otherwise, your answers should be based on 2000-02 discharges in that report if a total of at least 350 cases were reported for that time period. (Leapfrog could not use data in the 2003 report in its present form to rank hospitals into quartiles.)

New Jersey: 2003 (report dated Feb 2006) where only nine hospitals exceeded 350 reported cases. These results have been combined with results from 2002 (report dated Jun 2005).

New York (CABG): 2003 (report dated Oct 2005) – Your answers should be based on 2003 discharges, if at least 350 cases were reported for that year by your hospital in the 2001-03 report. Otherwise, your answers should be based on 2001-03 discharges in that report if a total of at least 350 cases were reported for that time period.

New York (PCI): 2003 (report dated May 2005) – Your answers should be based on the 2003 report, if at least 400 cases were reported by your hospital.

Pennsylvania: 2004 (report dated Jan 2006) where only six hospitals exceeded 350 reported cases. These results have been combined with results from 2003 (report dated Mar 2005).

You may base your responses only on publicly reported results for these time periods. To see if your hospital is included in these publicly-reported results, refer to the Publicly Reported Outcomes for Coronary Survey link on the home page of the online survey.

The Leapfrog Group is not using CABG mortality outcomes in Massachusetts, released in October 2004, due to the small number of hospitals with at least 400 observations reported in those results.



2B: Percutaneous Coronary Interventions (PCI)If you answered Yes to #2 above, complete these sections pertaining to this high-risk surgery.

Percutaneous Coronary Interventions (PCI) – Volume



_______

34) How many patients counted in question 33 died within 30 days post-operatively?Error: Reference source not found (annual average if 24 months of data)

_______

35) Number of surgeons performing Error: Reference source not found more than 75 procedures annually at this hospital location for this time period

_______

36) Number of procedures reported in question 33 that were performed by those surgeons included in question 35.

_______

If you are aware of publicly-reported results in these states for a more recent period, please contact the Leapfrog Help Desk.

7 Quartile Rank: CABG/PCI Mortality Ranking in Publicly Reporting StatesOutcomes referenced at Questions __ and __ were compiled by The Leapfrog Group based on publicly-reported data at the following sites. See the outcomes rankings in the Publicly Reported Outcomes for Coronary Artery Surgery link on the home page of the online survey. See data source references there and refer to state-specific sources for further information:

California –http://www.oshpd.ca.gov/HQAD/Outcomes/Studies/cabg/2000-2002Report/index.htmNew Jersey - http://www.state.nj.us/health/hcsa/cs.htmlNew York - www.health.state.ny.us/nysdoh/heart/heart_disease.htmPennsylvania - www.phc4.org/reports/cabg/04/default.htm

www.phc4.org/reports/cabg/03/default.htm

8 Participation in STS/ACC Performance Measurement SystemsIf your hospital currently participates and has begun submitting data for all such procedures but has not yet received any reports, you should indicate “Participating but no reports yet available" to get credit for participation. Return and update answers to the remaining questions when you receive your hospital’s first reported results; if you show more favorable performance than average you can receive additional credit.

9 Actual Operative Mortality Rate from National Performance Measures Reports (STS, ACC)Operative morality rate, including intra-operative plus 30-day post-op rate. Report this as a percentage, with two decimal-place precision.

10 Risk-Adjusted Expected Operative Mortality Rate from National Performance Measures ReportsOperative morality rate, including intra-operative plus 30-day post-op rate. This is the expected mortality rate based on all-hospital average mortality, but risk-adjusted for the severity of the hospital’s patient severity for the hospital’s reported cases. Report this as a percentage, with two decimal-place precision.


http://www.phc4.org/reports/cabg/03/default.htm

http://www.phc4.org/reports/cabg/04/default.htm

http://www.health.state.ny.us/nysdoh/heart/heart_disease.htm

http://www.state.nj.us/health/hcsa/cs.html

http://www.oshpd.ca.gov/HQAD/Outcomes/Studies/cabg/2000-2002Report/index.htm




YesNo


__________MMYYYYe.g. 122005


_______


_______

Percutaneous Coronary Interventions (PCI) – Publicly Reported OutcomesHospitals in New York ONLY.All other hospitals, skip questions #41-44.

Follow instructions in Publicly Reported Outcomes for Coronary Procedures link on the home page of the online survey when responding to questions #41-44.41) Are PCI mortality outcomes for your hospital included in your state-

sponsored public outcomes report for the most recently reported period Error: Reference source not found ? If no, skip to Question 45.

Yes No

42) If PCI mortality outcome results for your hospital are includedwith another hospital and/or publicly reported under a different hospitalname from that indicated in the Organization Information sectionof this survey, indicate the publicly-reported name of the hospital:

43) Does this most recent state-sponsored outcomes report show that your hospital’s most recently publicly-reported results are based on at least 400 PCIs?If no, skip to Question 45.

YesNo

44) Indicate the quartile ranking of your hospital’s risk-adjusted PCI mortality or ratio of observed to expected PCI mortality, as reported publicly by your state. More Information Error: Reference source not found

Most Favorable 25%Next 25% (2nd quartile)Next 25% (3rd quartile) Next 25% (4th quartile)

Percutaneous Coronary Intervention (PCI) – National Performance Measurement

If your hospital is in NY and you answered questions #41 and #43 both “Yes”, skip questions #45-48.

Indicate your hospital’s participation in and results from the following national performance measurement system.45) Has your hospital participated in the American College of Cardiology

National Cardiovascular Data Registry (ACC-NCDR™) quality YesNo



measurement program for percutaneous coronary interventions and submitted data for all such procedures in the most recent 12-month period for which performance reports have been released? More Information Error: Reference source not found If Yes, continue; otherwise skip to question #49.

Participating but no reports yet available

46) What is the most recent 12-month reporting period for which ACC-NCDR™ performance results are available? 12 months ending: __________

MMYYYYe.g. 122005

47) From the report for that time period, what was the actual mortality rate Error: Reference source not found as a percentage for percutaneous coronary interventions?Enter as percent with two decimal-place precision.

_______%

(e.g. 3.14)


rate Error: Reference source not found as a percentage for percutaneous coronary interventions?Enter as percent with two decimal-place precision.

_______%

(e.g. 4.23)




Percutaneous Coronary Intervention (PCI) – Process Measures of Quality

Indicate your hospital’s adherence to nationally endorsed procedure-specific process measures of quality specific to this procedure, if measured.

You need only measure and report two of the three indicators. You may measure and report on more than two, in which case survey results will be scored based on the two with the highest adherence rate.

InstructionsFor each of the two guidelines, indicate:

(a) whether your hospital has performed a medical record audit on all cases (or a sufficient sample of them) Error: Reference source not found for percutaneous coronary interventions over at least a 12-month period, but excluding cases admitted more than 24 months ago, and measured adherence to the Leapfrog expert panel-endorsed clinical process guideline for this procedure.*If no, skip (b) and (c) for this procedure.


(c) The number of cases in (b) that adhere to the Leapfrog expert panel-endorsed clinical process guideline for this procedure.

* Responses may be based on the same data reported to JCAHO for National Hospital Quality Measures where those data are recent and consistent Error: Reference source not found with these Nationally Endorsed Process Measures. Otherwise, hospitals can measure and report results as described here and in the Process Measures specifications (see link on home page).

Guideline (a)

Measured?if No,

skip (b) and (c)

(b)# Cases


( c)# Cases Adhere

(numerator)49) Patients with AMI receiving PTCA

within 90 minutes of arrival (PCI-1)YesNo ______ ______

50) Aspirin at arrival for AMI(PCI-2)

YesNo ______ ______

51) Aspirin prescribed at discharge(PCI-3)

YesNo ______ ______



2C: Aortic Valve ReplacementIf you answered Yes to #3 above, complete these sections pertaining to this high-risk surgery.

Aortic Valve Surgery –Volume



_______

53) How many patients counted in question 52 died within 30 days post-operatively?Error: Reference source not found(annual average if 24 months of data)

_______


_______


_______

Some hospitals collect data, either from public data reporting or internal credentialing, measuring surgeon-specific volume for this procedure at all facilities. Indicate in question 56 if this is so for this hospital; if Yes, continue with questions 57–59.56) Do you know surgeon-specific volume for this procedure at all facilities,


YesNo


__________MMYYYYe.g. 122005


_______


_______

Aortic Valve Surgery – National Performance Measurement

Indicate your hospital’s participation in and results from the following national performance measurement system.60) Has your hospital participated in the Society of Thoracic Surgeons (STS)

performance reporting system for aortic valve replacement surgery and submitted data for all such procedures in the most recent 12-month period for which performance reports have been released? More Information Error: Reference source not found If No, skip questions #61-63.


61) What is the most recent 12-month reporting period for which STS performance results are available? 12 months ending: __________

MMYYYYe.g. 122005



62) From the report for that time period, what was the actual mortality rate Error: Reference source not found as a percentage for aortic valve replacement surgery?Enter as percent with two decimal-place precision.

_______%

(e.g. 3.14)


rate Error: Reference source not found as a percentage for aortic valve replacement surgery?Enter as percent with two decimal-place precision.

_______%

(e.g. 4.23)


Aortic Valve Replacement (AVR) – Process Measures of Quality

Indicate your hospital’s adherence to nationally endorsed procedure-specific process measures of quality specific to this procedure, if measured.

You need only measure and report two of the three indicators. You may measure and report on more than two, in which case survey results will be scored based on the two with the highest adherence rate.

InstructionsFor each of the two guidelines, indicate:

(a) whether your hospital has performed a medical record audit on all cases (or a sufficient sample of them) Error: Reference source not found for Aortic Valve Replacement over at least a 12-month period, but excluding cases admitted more than 24 months ago, and measured adherence to the Leapfrog expert panel-endorsed clinical process guideline for this procedure.*If no, skip (b) and (c) for this procedure.




Guideline (a)

Measured?if No,

skip (b) and (c)

(b)# Cases


( c)# Cases Adhere

(numerator)64) Appropriate selection of antibiotic

prophylaxis for other cardiac surgeries (AVR-1)

YesNo ______ ______

65) Antibiotic prophylaxis within 1 hour pre-op for other cardiac surgeries (AVR-2)

YesNo ______ ______

66) Discontinue antibiotic prophylaxis <24 hrs post-op for other cardiac surgeries (AVR-3)

YesNo ______ ______



2D: Abdominal Aortic Aneurysm (AAA) Repair If you answered Yes to #4 above, complete these sections pertaining to this high-risk surgery.

Abdominal Aortic Aneurysm (AAA) Repair – Volume



_______


_______


_______


_______



YesNo


__________MMYYYYe.g. 122005


_______


_______



Abdominal Aortic Aneurysm (AAA) Repair – Process Measures of Quality

Indicate your hospital’s adherence to nationally endorsed procedure-specific process measures of quality specific to this procedure, if measured.InstructionsFor each of the two guidelines, indicate:

(a) whether your hospital has performed a medical record audit on all cases (or a sufficient sample of them) Error: Reference source not found for abdominal aortic aneurysm repairs over at least a 12-month period, but excluding cases admitted more than 24 months ago, and measured adherence to the Leapfrog expert panel-endorsed clinical process guidelines for this procedure.*If no, skip (b) and (c) for this procedure.

(b) the number of cases measured against the guideline, either all cases or the sample size, for this procedure, i.e., number of cases audited and meeting the criteria for inclusion in the denominator of the measure.



Guideline (a)

Measured?if No,

skip (b) and (c)

(b)# Cases


( c)# Cases Adhere

(numerator)75) Beta-blocker agent prior to induction

(AAA-1)YesNo ______ ______

76) Beta-blockers prescribed at discharge (AAA-2)

YesNo ______ ______



2E: Pancreatic Resections If you answered Yes to #5 above, complete these sections pertaining to this high-risk surgery.

Pancreatic Resections – Volume



_______


_______


_______


_______



YesNo


__________MMYYYYe.g. 122005


_______


_______



2F: Esophagectomy If you answered Yes to #6 above, complete these sections pertaining to this high-risk surgery.

Esophagectomy – Volume



_______


_______


_______


_______



YesNo


__________MMYYYYe.g. 122005


_______


_______



2G: Bariatric SurgeryIf you answered Yes to #7 above, complete these sections pertaining to this high-risk surgery.

Bariatric Surgery – Volume



_______

94) How many patients reported in question 93 above died within 30 days post-operatively?Error: Reference source not found(annual average if 24 months of data)

_______


_______


_______



YesNo


__________MMYYYYe.g. 122005


_______


_______



Bariatric Surgery – National Performance Measurement

Indicate your hospital’s participation in and results from the following national performance measurement system.101) Has your hospital participated in the American College of Surgeons

(ACS) NSQIP performance reporting system for bariatric surgery or the ACS Bariatric Surgery database and submitted data for all such procedures in the most recent 12-month period for which performance reports have been released? More Information13




If No, skip remaining questions in this section.102) What is the most recent 12-month reporting period for which ACS

NSQIP or the ACS Bariatric Surgery database performance results are available? 12 months ending:

MMYYYY e.g. 062006

Note: Leapfrog is currently reviewing with ACS the feasibility and opportunity for hospitals to share risk-adjusted mortality and complication rates from the NSQIP in the Leapfrog survey.

2H: Neonatal ICU and High-Risk Deliveries

Neonatal Intensive Care Unit(s)The following section of the survey asks for information relating to high-risk deliveries, complicated newborns, and the availability of neonatal intensive care units (Nicks) with particular characteristics. 103) Does your hospital operate a neonatal ICU, or is it co-located14 with

a hospital that operates a NICU, that admits or accepts transfers of complicated newborns15?If Yes, continue; otherwise skip to question #107. If the NICU is co-located in another hospital and your hospital immediately transfers all complicated newborns there, answer Questions 2 and 3 based on information pertaining to the co-located hospital’s NICU.

YesNo

104) For the most recently available 12- or 24-month period, what is the average daily census16 in the neonatal ICU (counting all patients regardless of condition)?

105) What time period is covered by this average census? New NICU: see more information Error: Reference source not found

o 12-months ending:o 24-months ending:

MMYYYY e.g. 032005

106) Does your hospital electively admit high-risk deliveries17?If No, skip remainder of this section.

YesNo

High-Risk Deliveries

Complete this section only if you answer Yes to question #110.

Indicate your hospital’s adherence to this nationally endorsed condition-specific process measure of quality specific to certain high-risk deliveries (see Process Measures link on home page), if measured.*

Guideline

107) Has your hospital has performed a medical record audit on all cases (or a sufficient sample of them) Error: Reference source not found for certain high-risk deliveries over at least a 12-month period, but excluding cases admitted more than 24 months ago, and measured adherence to the Leapfrog expert panel-endorsed clinical process guideline for these high-risk deliveries.*If no, skip questions 6 and 7.

YesNo

108) What is the number of cases measured against the guideline, either all cases or the sample size, for these deliveries i.e., number of cases audited and meeting the criteria for inclusion in the denominator of the measure.

______



109) What number of cases in question 6 adhere to the Leapfrog expert panel-endorsed clinical process guideline for this condition. ______

* Responses may be based on the same data reported to Vermont Oxford Network for this process measure where those data Otherwise, hospitals can measure and report results as described here and in the Process Measures specifications (see link on home page). See the Vermont Oxford Network Manual of Operations, version 10.2 at www.vtoxford.org/tools/2006Manualof Operationsver10_2.pdf


http://www.vtoxford.org/tools/2006Manualof%20Operationsver10_2.pdf


Endnotes and “More Information” Links

13 Participation in ACS-NSQIP Performance Measurement SystemsIf your hospital currently participates and has begun submitting data for all such procedures but has not yet received any reports, you should indicate “Participating but no reports yet available" to get credit for participation.

14 Co-located with a Hospital Having an NICUA hospital without a neonatal ICU but in immediate physical proximity to another hospital that has a neonatal ICU, e.g., a children’s hospital next door to which your hospital immediately transfers all complicated newborns, is considered as sharing a co-located NICU. "Immediate physical proximity” means the two facilities must be physically connected, either by a tunnel, an enclosed bridge, or the hospitals should abut each other so that the hallways readily connect. Based on available research evidence, the pivotal factor is that the neonatal team be able to attend the high-risk deliveries whenever a neonatal resuscitation might be necessary. If the hospitals are not immediately adjacent to each other, this isn't possible.

15 Complicated NewbornsComplicated newborns include those with:

birth weight <1500 grams; gestational age <32 weeks; diagnosis of major congenital anomalies; or, any combination of these conditions.

If your hospital has a neonatal ICU (or is co-located with a hospital that has a neonatal ICU) that admits or accepts transfers of neonates with these conditions, you should answer Yes to Question __.

16 NICU Average Daily CensusCompute the average daily census for ALL newborns in the NICU, regardless of the newborns’ medical condition. (Do not use the diagnosis/procedure coding criteria in the Medical Coding Criteria link on the home page of the online survey to determine the average daily census, since the census should count newborns regardless of condition.)

Round the census to the nearest whole number, e.g., 14.4999 rounds to 14; 14.500 rounds to 15.

If the NICU has been in operation for less than 12 months, compute the average daily census for the most recent 60 days of operations; do not report if fully operational less than 60 days. When the NICU reaches 12 months of full operations please re-submit the average daily census for all 12 months.

17 High-Risk Deliveries Electively AdmittedIncludes deliveries with:



expected birth weight <1500 grams; gestational age <32 weeks; pre-natal diagnosis of major congenital anomalies; or, any combination of these.

Not all women at risk for delivery of babies with these conditions are known beforehand to be at risk, e.g., an estimated 40% of mothers delivering babies with major congenital anomalies are identified at-risk prior to delivery. Therefore, deliveries in which these high-risk conditions were unknown prior to admission are not considered electively admitted high-risk deliveries.

If your hospital admits deliveries where these conditions are known prior to admission, then your hospital electively admits high-risk deliveries and you should answer Yes to Question __; otherwise, answer ‘No’.


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