Leapfrog Hospital Survey Hard Copy QUESTIONS & REPORTING PERIODS ENDNOTES MEASURE SPECIFICATIONS FAQS Table of Contents Welcome to the 2016 Leapfrog Hospital Survey........................................................................................... 6 Important Notes about the 2016 Survey ............................................................................................ 6 Overview of the 2016 Leapfrog Hospital Survey ................................................................................ 7 Pre-Submission Checklist .................................................................................................................. 9 Instructions for Submitting a Leapfrog Hospital Survey ................................................................... 10 Helpful Tips for Verifying Submission ......................................................................................... 11 Tips for updating or correcting a previously submitted Leapfrog Hospital Survey ...................... 11 Deadlines ......................................................................................................................................... 13 Deadlines for the 2016 Leapfrog Hospital Survey ...................................................................... 13 Deadlines Related to the Hospital Safety Score ......................................................................... 13 Technical Assistance........................................................................................................................ 14 Help Desk .................................................................................................................................... 14 Leapfrog Survey Users Group .................................................................................................... 14 Reporting Periods ............................................................................................................................. 15 PROFILE ..................................................................................................................................................... 18 PROFILE ................................................................................................................................................. 19 Facility Information ...................................................................................................................... 19 Demographic Information ............................................................................................................ 19 Contact Information ..................................................................................................................... 20 SECTION 1: BASIC HOSPITAL INFORMATION ....................................................................................... 22 Section 1: 2016 Basic Hospital Information ............................................................................................. 23 Section 1: 2016 Basic Hospital Reference Information ........................................................................... 24 What’s New in the 2016 Survey .................................................................................................. 24 Change Summary since Release................................................................................................ 24 Page Intentionally Left Blank ...................................................................................................................... 25 SECTION 2: COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) ..................................................... 26 Section 2: 2016 Computerized Physician Order Entry (CPOE) Standard .............................................. 27 Section 2: Computerized Physician Order Entry (CPOE) Reference Information .................................. 30 What’s New in the 2016 Survey .................................................................................................. 30 Change Summary since Release................................................................................................ 30 CPOE Frequently Asked Questions (FAQs) .................................................................................... 31 SECTION 3: EVIDENCE-BASED HOSPITAL REFERRAL (EBHR)........................................................... 33 Section 3: 2016 Evidence-Based Hospital Referral ................................................................................ 34 3A High-Risk Surgical Procedures Provided ................................................................................... 35 3B: Aortic Valve Replacement ......................................................................................................... 36 Aortic Valve Replacement (AVR) – Volume ................................................................................ 36 2 Version 6.3 First Release: April 1, 2016 Updated Release: August 22, 2016 Table of Contents Aortic Valve Replacement (AVR) – National Performance Measurement .................................. 37 Aortic Valve Replacement (AVR) – Regional Registries ............................................................ 38 3C: Abdominal Aortic Aneurysm (AAA) Repair ................................................................................ 39 Abdominal Aortic Aneurysm (AAA) Repair – Volume ................................................................. 39 3D: Pancreatic Resections ............................................................................................................... 40 Pancreatic Resections – Volume ................................................................................................ 40 3E: Esophagectomy ......................................................................................................................... 41 Esophagectomy – Volume .......................................................................................................... 41 Section 3: 2015 Evidence-Based Hospital Referral (EBHR) Reference Information .............................. 43 What’s New in the 2016 Survey .................................................................................................. 43 Change Summary since Release................................................................................................ 43 EBHR Frequently Asked Questions (FAQs) .................................................................................... 44 AVR Measure References ............................................................................................................... 45 AVR Volume Standard ................................................................................................................ 45 AVR Outcomes Specifications .................................................................................................... 46 AAA Repair Measure References .................................................................................................... 47 AAA Volume Standard ................................................................................................................ 47 Pancreatectomy Measure References ............................................................................................. 48 Pancreatectomy Volume Standard ............................................................................................. 48 Esophagectomy Measure References ............................................................................................. 50 Esophagectomy Volume Standard ............................................................................................. 50 Page Intentionally Left Blank ...................................................................................................................... 51 SECTION 4: MATERNITY CARE ............................................................................................................... 52 Section 4: 2016 Maternity Care ............................................................................................................... 53 4A Maternity Care ............................................................................................................................ 54 4B: Early Elective Deliveries ............................................................................................................ 55 4C: Cesarean Section ...................................................................................................................... 56 4D: Episiotomy ................................................................................................................................. 57 4E: Process Measures of Quality ..................................................................................................... 58 4F:High-Risk Deliveries .................................................................................................................... 59 High-Risk Deliveries .................................................................................................................... 59 Neonatal Intensive Care Unit(s) – Volume .................................................................................. 60 Neonatal Intensive Care Unit(s) – National Performance Measurement .................................... 60 Process Measure of Quality – Antenatal Steroids ...................................................................... 61 Section 4: 2016 Maternity Care Reference Information .........................................................................