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  • Data collection, analysis, and support services provided by Medstat. 2007 Evidence-Based Hospital Referral (EHR) LeapEach 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, 4Coronary 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 facilityPercutaneous coronary intervention2 • 400 or more total procedures/year for the hospital • 90% of total procedures by surgeons meeting surgeon-volume threshold of 75/year in one or more facilityAortic 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 facilityAbdominal aortic aneurysm repair • 50 or more total procedures/year for the hospital • 90% of total procedures by surgeons meeting surgeon-volume threshold of 8/year in one or more facilityPancreatic resection • 11 or more total procedures/year for the hospital • 90% of total procedures by surgeons meeting surgeon-volume threshold of 2/year in one or more facilityEsophagectomy • 13 or more total procedures/year for the hospital • 90% of total procedures by surgeons meeting surgeon-volume threshold of 2/year in one or more facilityBariatric 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: • Average daily neonatal ICU census > 15 for all• Delivery with gestational age <32 weeks babies regardless of diagnosis or expected birth weight <1500 grams• Delivery with prenatal diagnosis of major congenital anomalies1 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 24months 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 availableOctober 19, 2006 Page 1v4.0a 2007 Survey DRAFT
  • Data collection, analysis, and support services provided by Medstat.• 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.and2. 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.org ACC-NCDR™: www.accncdr.com/WebNCDR/Common ACS-NSQIP: acsnsqip.orgPartial credit is alternatively provided, for CABG, PCI, AVR, abdominal aortic aneurysm repair (AAA), orhigh-risk deliveries for 80% or higher adherence to nationally endorsed procedure-specific processmeasures 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 andcommonly utilized statewide performance assessment systems endorsed by The Leapfrog Group,fulfillment of the leap may be defined by favorable performance on statewide performance rather thancriteria 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 orobserved-to-expected mortality, or in the second quartile and adhering to the Nationally EndorsedProcedure-Specific Process Measures of Quality as above.Thus far, The Leapfrog Group has endorsed statewide performance assessment systems for CABGmortality in CA, NJ, NY, and PA, and for PCI in NY. To qualify for assessment by statewide performanceinstead of volume and the additional measures indicated above, a hospital’s results must be based on atleast 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 allsafely and legally transferable patients for such high-risk procedures or conditions, the leap does notapply for that procedure or condition. If you answer ‘No’ to any of the procedures listed in questions 1-5below, 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 Additional Information about the leap is available there as well.October 19, 2006 Page 2v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral LeapHigh-Risk Surgical Procedures ProvidedDoes 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 NoOn the home page of the online survey, see links to Medical Coding for High-Risk Procedures andConditions 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 reportingvolumes for these procedures. The same time period must be used to report all surgery volumes insubsequent EBHR sections8) Time period covered by o 12-months ending: MMYYYY these data o 24-months ending: 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. Basedon those responses, users will be asked to complete separate Web pages for each EBHR procedure orcondition which applies, one procedure or condition at a time, and save work after finishing eachprocedure or condition and between sessions.October 19, 2006 Page 3v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap2A: 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) – VolumeAnswer 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, measuringsurgeon-specific volume for this procedure at all faclities. Indicate in question 13 if this is so for thishospital; if Yes, continue with questions 14–16.13) Do you know surgeon-specific volume for this procedure at all facilities, Yes including this hospital location? No If No, skip questions 14–16.14) 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. MMYYYY e.g. 12200515) Number of surgeons performing5any of the procedures included in question 9 who performed at least 100 procedures annually at all facilities, including this _______ hospital location16) Number of procedures reported in question 9 that were performed by those surgeons included in question 15. _______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 ofthe online survey when responding to questions #17-20.17) Are CABG mortality outcomes for your hospital included in your state- Yes sponsored public outcomes report for the most recently reported No period6? If no, skip to Question 21.18) If CABG mortality outcome results for your hospital are included with another hospital and/or publicly reported under a different hospital name from that indicated in the Organization Information section of this survey, indicate the publicly-reported name of the hospital:19) Does this most recent state-sponsored outcomes report show that your Yes hospital’s most recently publicly-reported results are based on at least NoOctober 19, 2006 Page 4v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap 350 CABGs? If no, skip to Question 21.20) Indicate the quartile ranking of your hospital’s risk-adjusted CABG Most Favorable 25% mortality or ratio of observed to expected CABG mortality, as reported Next 25% (2nd quartile) publicly by your state. (More Information7) 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 measurementsystem.21) Has your hospital participated in the Society of Thoracic Surgeons (STS) Yes performance reporting system for coronary artery bypass graft surgery No and submitted data for all such procedures in the most recent 12-month Participating but no period for which performance reports have been released? More reports yet available Information8 If Yes, continue with questions #22-24; otherwise, skip to question 25.22) What is the most recent 12-month reporting period for which STS performance results are available? 12 months ending: __________ MMYYYY e.g. 12200523) 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 respondOctober 19, 2006 Page 5v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral LeapCoronary 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 ofquality 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 morethan two, in which case survey results will be scored based on the two with the highest adherence rate.InstructionsFor 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 wherethose data are recent and consistent12 with these Nationally Endorsed Process Measures. Otherwise, hospitals canmeasure and report results as described here and in the Process Measures specifications (see link on home page). (a) (b) ( c) Guideline Measured? # Cases # Cases if No, Measured Adhere skip (b) and (c) (denominator) (numerator)25) Aspirin prescribed at discharge Yes (CABG-1) No ______ ______26) IMA grafting for isolated primary Yes CABG (CABG-2) No ______ ______27) Beta-blocker within 24 hours after Yes surgery (CABG-3) No ______ ______28) Beta-blockers prescribed at discharge Yes (CABG-4) No ______ ______29) Lipid-lowering therapy at discharge Yes (CABG-5) No ______ ______30) Appropriate selection of antibiotic Yes prophylaxis (CABG-7) No ______ ______31) Antibiotic prophylaxis within 1 hour Yes pre-op (CABG-8) No ______ ______32) Discontinue antibiotic prophylaxis <24 Yes hrs post-op (CABG-9) No ______ ______October 19, 2006 Page 6v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap2B: Percutaneous Coronary Interventions (PCI)If you answered Yes to #2 above, complete these sections pertaining to this high-risk surgery.Percutaneous Coronary Interventions (PCI) – VolumeAnswer questions #33-36 for the time period indicated in question #8.33) Total annual procedure volume at this hospital location Annual number of procedures for the volume reporting period (annual _______ average if 24 months of data)34) How many patients counted in question 33 died within 30 days post- operatively?4 _______ (annual average if 24 months of data)35) Number of surgeons performing5 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. _______Some hospitals collect data, either from public data reporting or internal credentialing, measuringsurgeon-specific volume for this procedure at all faclities. Indicate in question 37 if this is so for thishospital; if Yes, continue with questions 38–40.37) Do you know surgeon-specific volume for this procedure at all facilities, Yes including this hospital location? No If No, skip questions 38–40.38) 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. MMYYYY e.g. 12200539) Number of surgeons performing5 any of the procedures included in question 33 who performed at least 75 procedures annually at all facilities, including _______ this hospital location40) Number of procedures reported in question 33 that were performed by those surgeons included in question 39. _______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 ofthe online survey when responding to questions #41-44.41) Are PCI mortality outcomes for your hospital included in your state- Yes sponsored public outcomes report for the most recently reported No period6? If no, skip to Question 45.42) If PCI mortality outcome results for your hospital are included with another hospital and/or publicly reported under a different hospital name from that indicated in the Organization Information section of this survey, indicate the publicly-reported name of the hospital:43) Does this most recent state-sponsored outcomes report show that your Yes hospital’s most recently publicly-reported results are based on at least NoOctober 19, 2006 Page 7v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap 400 PCIs? If no, skip to Question 45.44) Indicate the quartile ranking of your hospital’s risk-adjusted PCI mortality Most Favorable 25% or ratio of observed to expected PCI mortality, as reported publicly by Next 25% (2nd quartile) your state. More Information7 Next 25% (3rd quartile) Next 25% (4th quartile)Percutaneous Coronary Intervention (PCI) – National Performance MeasurementIf 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 measurementsystem.45) Has your hospital participated in the American College of Cardiology Yes National Cardiovascular Data Registry (ACC-NCDR™) quality No measurement program for percutaneous coronary interventions and Participating but no submitted data for all such procedures in the most recent 12-month reports yet available period for which performance reports have been released? More Information8 If Yes, continue; otherwise skip to question #49.46) What is the most recent 12-month reporting period for which ACC- NCDR™ performance results are available? 12 months ending: __________ MMYYYY e.g. 12200547) From the report for that time period, what was the actual mortality rate9 as a percentage for percutaneous coronary interventions? _______% Enter as percent with two decimal-place precision. (e.g. 3.14)  Prefer not to respond48) From the same report, what was the risk-adjusted expected mortality rate10 as a percentage for percutaneous coronary interventions? _______% Enter as percent with two decimal-place precision. (e.g. 4.23)  Prefer not to respondOctober 19, 2006 Page 8v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral LeapPercutaneous Coronary Intervention (PCI) – Process Measures of QualityIndicate your hospital’s adherence to nationally endorsed procedure-specific process measures ofquality specific to this procedure, if measured.You need only measure and report two of the three indicators. You may measure and report on morethan 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)11 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. (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.* Responses may be based on the same data reported to JCAHO for National Hospital Quality Measures wherethose data are recent and consistent12 with these Nationally Endorsed Process Measures. Otherwise, hospitals canmeasure and report results as described here and in the Process Measures specifications (see link on home page). (a) (b) ( c) Guideline Measured? # Cases # Cases if No, Measured Adhere skip (b) and (c) (denominator) (numerator)49) Patients with AMI receiving PTCA Yes within 90 minutes of arrival (PCI-1) No ______ ______50) Aspirin at arrival for AMI Yes (PCI-2) No ______ ______51) Aspirin prescribed at discharge Yes (PCI-3) No ______ ______October 19, 2006 Page 9v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap2C: Aortic Valve ReplacementIf you answered Yes to #3 above, complete these sections pertaining to this high-risk surgery.Aortic Valve Surgery –VolumeAnswer questions #52-55 for the time period indicated in question #8.52) Total annual procedure volume at this hospital location Annual number of procedures for the volume reporting period (annual _______ average if 24 months of data)53) How many patients counted in question 52 died within 30 days post- operatively?4 _______ (annual average if 24 months of data)54) Number of surgeons performing5 more than 22 procedures annually at this hospital location for this time period _______55) Number of procedures reported in question 52 that were performed by those surgeons included in question 54. _______Some hospitals collect data, either from public data reporting or internal credentialing, measuringsurgeon-specific volume for this procedure at all facilities. Indicate in question 56 if this is so for thishospital; if Yes, continue with questions 57–59.56) Do you know surgeon-specific volume for this procedure at all facilities, Yes including this hospital location? No If No, skip questions 57–59.57) 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. MMYYYY e.g. 12200558) Number of surgeons performing5 any of the procedures included in question 52 who performed at least 22 procedures annually at all facilities, including _______ this hospital location59) Number of procedures reported in question 52 that were performed by those surgeons included in question 58. _______Aortic Valve Surgery – National Performance MeasurementIndicate your hospital’s participation in and results from the following national performance measurementsystem.60) Has your hospital participated in the Society of Thoracic Surgeons (STS) Yes performance reporting system for aortic valve replacement surgery and No submitted data for all such procedures in the most recent 12-month Participating but no period for which performance reports have been released? More reports yet available Information8 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: __________ MMYYYY e.g. 122005October 19, 2006 Page 10v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap62) From the report for that time period, what was the actual mortality rate9 as a percentage for aortic valve replacement surgery? _______% Enter as percent with two decimal-place precision. (e.g. 3.14)  Prefer not to respond63) From the same report, what was the risk-adjusted expected mortality rate10 as a percentage for aortic valve replacement surgery? _______% Enter as percent with two decimal-place precision. (e.g. 4.23)  Prefer not to respondAortic Valve Replacement (AVR) – Process Measures of QualityIndicate your hospital’s adherence to nationally endorsed procedure-specific process measures ofquality specific to this procedure, if measured.You need only measure and report two of the three indicators. You may measure and report on morethan 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)11 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. (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.* Responses may be based on the same data reported to JCAHO for National Hospital Quality Measures wherethose data are recent and consistent12 with these Nationally Endorsed Process Measures. Otherwise, hospitals canmeasure and report results as described here and in the Process Measures specifications (see link on home page). (a) (b) ( c) Guideline Measured? # Cases # Cases if No, Measured Adhere skip (b) and (c) (denominator) (numerator)64) Appropriate selection of antibiotic Yes prophylaxis for other cardiac No ______ ______ surgeries (AVR-1)65) Antibiotic prophylaxis within 1 hour Yes pre-op for other cardiac surgeries No ______ ______ (AVR-2)66) Discontinue antibiotic prophylaxis <24 Yes hrs post-op for other cardiac surgeries No ______ ______ (AVR-3)October 19, 2006 Page 11v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap2D: Abdominal Aortic Aneurysm (AAA) RepairIf you answered Yes to #4 above, complete these sections pertaining to this high-risk surgery.Abdominal Aortic Aneurysm (AAA) Repair – VolumeAnswer questions #67-70 for the time period indicated in question #8.67) Total annual procedure volume at this hospital location Annual number of procedures for the volume reporting period (annual _______ average if 24 months of data)68) How many patients counted in question 67 died within 30 days post- operatively?4 _______ (annual average if 24 months of data)69) Number of surgeons performing5 more than 8 procedures annually at this hospital location for this time period _______70) Number of procedures reported in question 67 that were performed by those surgeons included in question 69. _______Some hospitals collect data, either from public data reporting or internal credentialing, measuringsurgeon-specific volume for this procedure at all facilities. Indicate in question 71 if this is so for thishospital; if Yes, continue with questions 72–74.71) Do you know surgeon-specific volume for this procedure at all facilities, Yes including this hospital location? No If No, skip questions 72–74.72) 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. MMYYYY e.g. 12200573) Number of surgeons performing5 any of the procedures included in question 67 who performed at least 8 procedures annually at all facilities, including this _______ hospital location74) Number of procedures reported in question 67 that were performed by those surgeons included in question 73. _______October 19, 2006 Page 12v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral LeapAbdominal Aortic Aneurysm (AAA) Repair – Process Measures of QualityIndicate your hospital’s adherence to nationally endorsed procedure-specific process measures ofquality 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)11 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. (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 wherethose data are recent and consistent12 with these Nationally Endorsed Process Measures. Otherwise, hospitals canmeasure and report results as described here and in the Process Measures specifications (see link on home page). (a) (b) ( c) Guideline Measured? # Cases # Cases if No, Measured Adhere skip (b) and (c) (denominator) (numerator)75) Beta-blocker agent prior to induction Yes (AAA-1) No ______ ______76) Beta-blockers prescribed at discharge Yes (AAA-2) No ______ ______October 19, 2006 Page 13v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap2E: Pancreatic ResectionsIf you answered Yes to #5 above, complete these sections pertaining to this high-risk surgery.Pancreatic Resections – VolumeAnswer questions #77-80 for the time period indicated in question #8.77) Total annual procedure volume at this hospital location Annual number of procedures for the volume reporting period (annual _______ average if 24 months of data)78) How many patients counted in question 77 died within 30 days post- operatively?4 _______ (annual average if 24 months of data)79) Number of surgeons performing5 more than 2 procedures annually at this hospital location for this time period _______80) Number of procedures reported in question 77 that were performed by those surgeons included in question 79. _______Some hospitals collect data, either from public data reporting or internal credentialing, measuringsurgeon-specific volume for this procedure at all faclities. Indicate in question 81 if this is so for thishospital; if Yes, continue with questions 82–84.81) Do you know surgeon-specific volume for this procedure at all facilities, Yes including this hospital location? No If No, skip questions 82–84.82) 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. MMYYYY e.g. 12200583) Number of surgeons performing5 any of the procedures included in question 77 who performed at least 2 procedures annually at all facilities, including this _______ hospital location84) Number of procedures reported in question 77 that were performed by those surgeons included in question 83. _______October 19, 2006 Page 14v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap2F: EsophagectomyIf you answered Yes to #6 above, complete these sections pertaining to this high-risk surgery.Esophagectomy – VolumeAnswer questions #85-88 for the time period indicated in question #8.85) Total annual procedure volume at this hospital location Annual number of procedures for the volume reporting period (annual _______ average if 24 months of data)86) How many patients counted in question 85 died within 30 days post- operatively?4 _______ (annual average if 24 months of data)87) Number of surgeons performing5 more than 2 procedures annually at this hospital location for this time period _______88) Number of procedures reported in question 85 that were performed by those surgeons included in question 87. _______Some hospitals collect data, either from public data reporting or internal credentialing, measuringsurgeon-specific volume for this procedure at all facilities. Indicate in question 89 if this is so for thishospital; if Yes, continue with questions 90–92.89) Do you know surgeon-specific volume for this procedure at all facilities, Yes including this hospital location? No If No, skip questions 90–92.90) 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. MMYYYY e.g. 12200591) Number of surgeons performing5 any of the procedures included in question 85 who performed at least 2 procedures annually at all facilities, including this _______ hospital location92) Number of procedures reported in question 85 that were performed by those surgeons included in question 91. _______October 19, 2006 Page 15v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap2G: Bariatric SurgeryIf you answered Yes to #7 above, complete these sections pertaining to this high-risk surgery.Bariatric Surgery – VolumeAnswer questions #93-96 for the time period indicated in question #8.93) Total annual procedure volume at this hospital location Annual number of procedures for the volume reporting period (annual _______ average if 24 months of data)94) How many patients reported in question 93 above died within 30 days post- operatively?4 _______ (annual average if 24 months of data)95) Number of surgeons performing5 more than 20 procedures annually at this hospital location for this time period _______96) Number of procedures reported in question 93 that were performed by those surgeons included in question 95. _______Some hospitals collect data, either from public data reporting or internal credentialing, measuringsurgeon-specific volume for this procedure at all faclities. Indicate in question 97 if this is so for thishospital; if Yes, continue with questions 98–100.97) Do you know surgeon-specific volume for this procedure at all facilities, Yes including this hospital location? No If No, skip questions 98–100.98) 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. MMYYYY e.g. 12200599) Number of surgeons performing5 any of the procedures included in question 93 who performed at least 20 procedures annually at all facilities, including _______ this hospital location100)Number of procedures reported in question 93 that were performed by those surgeons included in question 99. _______Bariatric Surgery – National Performance MeasurementIndicate your hospital’s participation in and results from the following national performance measurementsystem.101)Has your hospital participated in the American College of Surgeons Yes (ACS) NSQIP performance reporting system for bariatric surgery or the No ACS Bariatric Surgery database and submitted data for all such Participating but no procedures in the most recent 12-month period for which performance reports yet available 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 MMYYYY NSQIP or the ACS Bariatric Surgery database performance results are e.g. 062006 available? 12 months ending:October 19, 2006 Page 16v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral LeapNote: 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 DeliveriesNeonatal Intensive Care Unit(s)The following section of the survey asks for information relating to high-risk deliveries, complicatednewborns, 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 Yes hospital that operates a NICU, that admits or accepts transfers of No 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.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 o 12-months ending: MMYYYY census? New NICU: see more information16 o 24-months ending: e.g. 032005106)Does your hospital electively admit high-risk deliveries17? Yes If No, skip remainder of this section. NoHigh-Risk DeliveriesComplete this section only if you answer Yes to question #110.Indicate your hospital’s adherence to this nationally endorsed condition-specific process measure ofquality specific to certain high-risk deliveries (see Process Measures link on home page), if measured.* Guideline107) Has your hospital has performed a medical record audit on all cases Yes (or a sufficient sample of them)11 for certain high-risk deliveries over No 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 7.108) 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 wherethose data Otherwise, hospitals can measure and report results as described here and in the Process Measuresspecifications (see link on home page). See the Vermont Oxford Network Manual of Operations, version 10.2 atwww.vtoxford.org/tools/2006Manualof Operationsver10_2.pdfOctober 19, 2006 Page 17v4.0a 2007 Survey DRAFT
  • 2007 Evidence-Based Hospital Referral Leap Endnotes and “More Information” LinksOctober 19, 2006 Page 18v4.0a 2007 Survey DRAFT
  • 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 isa third party audit to affirm accuracy of submitted clinical data; 3) there is supplementary collection of clinicalvariables present upon admission that, when combined with routinely collected administrative data, predict alarge portion of inter-hospital mortality differences; 4) data cover at least a 12-month period; and, 5) samplesizes per hospital are adequate to achieve statistically stable results.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 priorto the submission date of this survey, answer ‘No’.4 Operating MortalityInclude intra-operative deaths as well as deaths within 30 days following surgery, whether in-hospital or not. Thisis 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 primarysurgeon in charge. Do not attribute the surgery to any other surgeon, including those present but assisting in theoperation.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 yourhospital is included in these publicly-reported results, refer to the Publicly Reported Outcomes for CoronarySurvey 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 tothe small number of hospitals with at least 400 observations reported in those results.If you are aware of publicly-reported results in these states for a more recent period, please contact the LeapfrogHelp 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-reporteddata at the following sites. See the outcomes rankings in the Publicly Reported Outcomes for Coronary ArterySurgery link on the home page of the online survey. See data source references there and refer to state-specificsources for further information: California – http://www.oshpd.ca.gov/HQAD/Outcomes/Studies/cabg/2000-2002Report/index.htm New Jersey - http://www.state.nj.us/health/hcsa/cs.html New York - www.health.state.ny.us/nysdoh/heart/heart_disease.htm Pennsylvania - www.phc4.org/reports/cabg/04/default.htm www.phc4.org/reports/cabg/03/default.htm8 Participation in STS/ACC Performance Measurement SystemsIf your hospital currently participates and has begun submitting data for all such procedures but has not yetreceived 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; ifyou 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 twodecimal-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 ratebased on all-hospital average mortality, but risk-adjusted for the severity of the hospital’s patient severity for thehospital’s reported cases. Report this as a percentage, with two decimal-place precision.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 forcases from at least a 12-month period (unless your hospital only recently started offering these services, inwhich case for the time period that you have offered those services.) You need NOT use more than 12 monthsof historical experience to increase the eligible cases beyond 60; just measure and report based on ALL eligiblecases 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 randomlysample 60 of them for the denominator of each indicator, and measure and report adherence based on thatsample. When sampling from a larger population of cases, this is the minimum number of cases needed to makea statistically reliable statement of percentage adherence to the process guideline.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 ProcessMeasurement systems, e.g., the JCAHO National Hospital Quality Measures set. Hospitals that submit data toJCAHO for those measures may use the same data to respond to the Leapfrog survey questions for that samemeasure.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.13 Participation in ACS-NSQIP Performance Measurement SystemsIf your hospital currently participates and has begun submitting data for all such procedures but has not yetreceived 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 neonatalICU, 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 bephysically connected, either by a tunnel, an enclosed bridge, or the hospitals should abut each other so that thehallways readily connect. Based on available research evidence, the pivotal factor is that the neonatal team beable to attend the high-risk deliveries whenever a neonatal resuscitation might be necessary. If the hospitals arenot immediately adjacent to each other, this isnt 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 oraccepts 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’ medicalcondition. (Do not use the diagnosis/procedure coding criteria in the Medical Coding Criteria link on the homepage of the online survey to determine the average daily census, since the census should count newbornsregardless 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 recent60 days of operations; do not report if fully operational less than 60 days. When the NICU reaches 12 months offull 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., anestimated 40% of mothers delivering babies with major congenital anomalies are identified at-risk prior todelivery. Therefore, deliveries in which these high-risk conditions were unknown prior to admission are notconsidered electively admitted high-risk deliveries.
  • If your hospital admits deliveries where these conditions are known prior to admission, then your hospitalelectively admits high-risk deliveries and you should answer Yes to Question __; otherwise, answer ‘No’.