PROPOSED CHANGES TO THE 2016 LEAPFROG HOSPITAL SURVEY

PROPOSED CHANGES TO THE 2016 LEAPFROG HOSPITAL SURVEY OPEN FOR PUBLIC COMMENT Eh yer, The Lepfrog Group s tem of reserhers reviews the literture nd onvenes expert pnels to review survey ontent to ensure the Lepfrog Hospitl Survey ligns with the ltest siene s well the puli reporting needs for purhsers nd onsumers. One list of proposed hnges is finlized for the next yer s survey, Lepfrog releses those hnges for puli omment. Comments re reviewed y Lepfrog s tem of reserhers nd frequently used to further refine the survey. The proposed hnges to the Lepfrog Hospitl Survey in 2016 re outlined elow. To provide puli omment, plese respond y ompleting the puli omment form loted here. Comments will e epted until COB Deemer 22, 2015. We re grteful to those who tke the time to sumit omments eh yer. These omments ring enormous vlue to Lepfrog s tem nd ensure the survey is vlule to hospitls, purhsers, nd onsumers. For informtion on the 2015 Lepfrog Hospitl Survey visit www.lepfroghospitlsurvey.org. PROPOSED CONTENT CHANGES SECTION 1: BASIC HOSPITAL INFORMATION No sustntive hnges proposed to this setion. SECTION 2: COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) No sustntive hnges proposed to this setion. SECTION 3: EVIDENCE-BASED HOSPITAL REFERRAL (EBHR) Due to the ntionl trnsition to ICD-10 dministrtive oding on Otoer 1, 2015, the 12-month reporting period for ll four surgil proedures (orti vlve replement, dominl orti neurysm repir, pnreti resetion, nd esophgel resetion) inluded in Setion 3 EBHR, will e Otoer 1, 2014 to Septemer 30, 2015 to llow hospitls to report on the mesures using ICD-9 oded dministrtive dt. There re no proposed hnges to the soring lgorithm for this stndrd. See pges 8-10 in the 2015 Soring Algorithms for more informtion. Over the next yer, Lepfrog will e onvening ntionl expert pnel with the gol of developing 1

new stndrd for surgil sfety nd qulity tht onsiders hospitl nd surgeon volume nd outomes, s well s protools tht hospitls hve in ple to monitor nd prevent inpproprite use. We welome suggestions nd omments on ttining this gol. SECTION 4: MATERNITY CARE No sustntive hnges proposed to this setion. See ICD-10 speifitions nd updtes regrding reporting periods in Appendix I. There re no proposed hnges to the soring lgorithm for this stndrd. See pges 11-14 in the 2015 Soring Algorithms for more informtion. SECTION 5: ICU PHYSICIAN STAFFING (IPS) We re proposing n dditionl response type for questions #5 nd #6 in Setion 5: ICU Physiin Stffing (IPS). The new response type will give hospitls the opportunity to report 24/7 intensivist overge in n pplile ICU. See detils elow. Yes Question #5: When these physiins re not present in these ICUs on-site or vi telemediine, do they return more thn 95% of lls/pges from these units within five minutes, sed on quntified nlysis of notifition devie response time? No Not pplile, Intensivists re present 24/7 Question #6: When these physiins re not present on-site in the ICU or not le to reh n ICU ptient within 5 minutes, n they rely on physiin, physiin ssistnt, nurse prtitioner, or FCCS-ertified nurse effetor who is in the hospitl nd le to reh these ICU ptients within five minutes in more thn 95% of the ses, sed on quntified nlysis of notifition devie response time? Yes No Not pplile, Intensivists re present 24/7 There re no proposed hnges to the soring lgorithm for this stndrd. Hospitls tht respond Not pplile, Intensivists re present 24/7 to oth question #5 nd question #6 will e sored in the sme wy s hospitls tht respond yes to those questions. See pge 15 of the 2015 Soring Algorithms for more informtion. 2

SECTION 6: NQF SAFE PRACTICES SCORE Erlier this yer, Lepfrog onvened ntionl expert pnel to updte the wording of the sfe prtie elements inluded in Setion 6 NQF Sfe Prties Sore to provide greter lrity to hospitls, nd ensure urte, stndrd responses ross ll hospitls. In ddition to wording updtes, the pnel lso reommended the following hnges to e onsistent with the NQF Sfe Prties for Better Helthre 2010 Updte nd the 2010 Sfe Prties Audit ompleted y NQF in 2014 (See tles 1 nd 2 elow). Plese see Appendix IV for detiled wording hnges. In ddition, the Culture of Sfety ntionl expert pnel performed omprehensive review of Sfe Prtie 2 Culture Mesurement, Feedk, nd Intervention nd hs identified gps in this prtie. The pnel is reommending the ddition of four (4) sfe prtie elements (see Appendix IV for detils). In response to questions out whih sfety ulture surveys meet the intent of Sfe Prtie 2, the pnel hs lso developed set of Guidelines for Culture of Sfety Survey tht Demonstrtes Vlidity, Consisteny, nd Reliility tht will e rolled out in 2016. Plese see Appendix II. Tle 1: Summry of Chnges to NQF Sfe Prties Sore NQF Sfe Prtie Weighting (totl possile points) 2015 Survey - # of Sfe Prtie Elements 2016 Survey - # of Sfe Prtie Elements Chnge in # of Sfe Prtie Elements 1 Culture of Sfety Ledership Strutures nd Systems 120 14 13-1 2 Culture Mesurement, Feedk, nd Intervention 20 9 13 +4 3 Temwork Trining nd Skill Building 40 10 11 +1 4 Risks nd Hzrds 120 11 12 +1 9 Nursing Workfore 100 19 18-2 17 Medition Reonilition 35 15 15 0 19 Hnd Hygiene 30 10 10 0 23 Helth Cre Assoited Complitions in Ventilted Ptients 20 12 12 0 3

There re no proposed hnges to the soring lgorithm for this stndrd. See pges 17-18 of the 2015 Soring Algorithms for more informtion. SECTION 7: MANAGING SERIOUS ERRORS New Su-Setion on Antiioti Stewrdship Progrms In order to support ntionl efforts round the responsile use of ntiiotis in hospitls, Lepfrog will e pulily reporting hospitl ompline with the CDC's stndrds for Antiioti Stewrdship Progrms. The CDC hs pulished seven Core Elements of Antiioti Stewrdship Progrms: Ledership ommitment Aountility Drug Expertise Ation Trking Reporting Edution To ollet this informtion regrding hospitl doption of these seven Core Elements, Lepfrog will use set of 12 questions from the NHSN Annul Hospitl Survey on ntiioti stewrdship progrms (questions #23-34 from the NHSN Annul Hospitl Survey). For omplete list of questions, plese see Appendix III. Proposed Soring Algorithm Hospitls tht hve dopted ll seven of the Core Elements will e sored s Fully Meets the Stndrd. Hospitls tht hve dopted fewer thn seven of the Core Elements will e sored s Willing to Report. Lepfrog is intending to pulily report this mesure in 2016. New Hospitl-Aquired Infetion Mesures In response to requests from hospitls, Lepfrog will inlude three dditionl hospitl-quired infetion mesures on the survey: MRSA, CDI, nd SSI fter Mjor Colon Surgery. These mesures ome diretly from the NHSN nd re in use in one or more CMS inptient progrms. Unlike the entrl-line ssoited lood strem infetion nd theter-ssoited urinry trt infetion mesures, these mesures do not require hospitls to report y speifi unit or wrd, s they re hospitlwide inptient or surgery speifi mesures. Therefore, Lepfrog will not sk hospitls to report numertor nd denomintor. Insted, hospitls will report the stndrdized infetion rtio (SIR) s lulted y NHSN for speified 12- month reporting period. Hospitls sumitting survey prior to Septemer 1, 2016 will e sked to report on the 12-months ending Deemer 31, 2015. Hospitls sumitting survey on or fter Septemer 1, 2016 will e sked to report on the 12-months ending June 30, 2016. 4

Proposed Soring Algorithm Performne Ctegory SSI Colon SIR MRSA SIR CDI SIR Fully Meets the Stndrd 0.386 0.373 0.450 Sustntil Progress > 0.386 nd 0.825 > 0.373 nd 0.766 > 0.450 nd 0.782 Some Progress > 0.825 nd 1.375 > 0.766 nd 1.251 > 0.782 nd 1.093 Willing to Report >1.375 >1.251 >1.093 Does Not Apply Hospitl does not perform mjor olon surgery Lepfrog is proposing to pulily report these results in 2016. In ddition, Lepfrog ntiiptes using these results in the Fll 2016 Hospitl Sfety Sore for eligile hospitls. ICD-10 Codes for Hospitl-Aquired Conditions Plese see ICD-10 speifitions nd updtes regrding reporting periods in Appendix I. There re no proposed hnges to the soring lgorithm for the stndrds in Setion 7 Mnging Serious Errors. See pges 19-24 of the 2015 Soring Algorithms for more informtion. SECTION 8: BAR CODE MEDICATION ADMINISTRATION (BCMA) The BCMA expert pnel determined tht the initil fous of Lepfrog s BCMA stndrd should e the use of BCMA t the edside in dministrting meditions. The BCMA expert pnel mde reommendtion for Lepfrog s stndrd sed on the results from this setion of the 2015 Lepfrog Hospitl Survey. The proposed stndrd is omposite of four omponents: % Units: A hospitl s implementtion of BCMA throughout the hospitl, s mesured y the perentge of units with fous on dult nd peditri medil nd/or surgil units, lor nd delivery units, nd intensive re units (dult, peditri, nd neontl). % Compline: A hospitl s ompline with ptient nd medition sns prior to med dministrtion. 5

Deision Support: The types of deision support tht the hospitl s BCMA system offers, inluding: 1. Wrong ptient 2. Wrong medition 3. Wrong dose 4. Wrong time (e.g., erly/lte wrning; wrning tht medition nnot e dministered twie within given window of time) 5. Vitl sign hek 6. Ptient-speifi llergy hek 7. Seond nurse hek needed Workrounds: A hospitl s strutures to monitor nd redue workrounds, inluding: 1. Hs forml ommittee tht meets routinely to review dt reports on BCMA system use 2. Hs k-up systems for hrdwre filures 3. Hs help desk tht provides timely responses to urgent BCMA issues in rel-time 4. Conduts preventtive mintenne on hrdwre 5. Conduts rel-time oservtions of users using the BCMA system 6. Engges nursing ledership t the unit level on BCMA use Proposed Soring Algorithm Fully Meets Stndrd Sustntil Progress Some Progress Willing to Report % Units 100% % Compline 95% Deision Support 7 out of 7 Hospitl meets 3 out of 4 stndrds Hospitl meets 2 out of 4 stndrds Hospitl meets 1 or 0 out of 4 stndrds Workrounds 6 out of 6 These results will e pulily reported in 2016. SECTION 9: RESOURCE USE Currently, in Setion 9 Resoure Use for Common Aute Conditions, Lepfrog sks hospitls to report on oth risk-djusted lengths of sty nd redmission rtes for three ommon ute onditions: AMI, Hert Filure, nd Pneumoni. In 2016, due to the ntionl trnsition to ICD-10 dministrtive oding nd the hllenges of updting the risk djustment model given the srity of pulished ICD-10 dministrtive dt sets, Lepfrog will remove the length of sty mesures from this setion of the survey. 6

The redmission rtes re reported diretly from the CMS Hospitl Compre wesite. These rtes re omined into volume-weighted omposite for n overll sore. In ddition to removing the length of sty mesures, we re plnning on severl dditionl hnges: New Mesures: We will dd three dditionl redmission mesures to this setion to etter lign with the CMS Redmission Redution Progrm: CABG, COPD, nd THA/TKA. Soring: Lepfrog will ontinue to lulte volume-weighted omposite sore for hospitl redmissions. The omposite will e mde up of six, rther thn three mesures. No other hnges to the soring lgorithm re ntiipted. See pges 28-30 for desription of the 2015 Soring Algorithms. Dt Entry: Hospitls will no longer need to look up the volume nd redmission rte for eh mesure. This informtion will e pre-populted in eh survey sed on the hospitl s Medire Provider Numer. Hospitls will still need to respond to some filter questions nd ffirm the setion efore it n e sumitted. Puli Reporting: Lepfrog plns to pulily report this updted redmissions omposite in 2016. 7

NON-CONTENT RELATED CHANGES NEW ONLINE SURVEY TOOL & SURVEY LAUNCH DATE ON APRIL 15, 2015 Lepfrog will e lunhing new nd improved survey wesite nd online survey tool in 2016. The new online survey tool hs een re-designed with feedk from hospitls nd hospitl systems ross the ountry. Due to the development nd testing of the new tool, the online survey tool will not e ville to hospitls until April 15, 2015. The hrd opy of the survey nd soring lgorithms, s well s tools nd supporting mterils will e ville on April 1 st so tht hospitls n egin to ollet dt nd reord responses in the hrd opy of the survey. However, the online survey tool nd CPOE Evlution Tool will not e ville for sumitting responses until April 15 th. The new online survey tool will inlude three importnt funtions: 1. Profile: The profile setion of the online survey will e ville to hospitls yer-round to ensure tht hospitls re lwys le to provide the most urrent informtion regrding hospitl nme, ddress (physil nd miling), ontt informtion, MPN, nd other generl informtion tht my hnge during the yer. 2. New Survey Dshord: The newly designed survey dshord will inlude setion nd su-setion nvigtion, setion sttus, nd list of dt entry errors y setion. Hospitls will lso ffirm setions nd sumit the survey diretly from the dshord. Hospitls will e le to run desk review efore they sumit, s well s print opies of their lst sved survey, lst sumitted survey, nd previous yer s survey. Hospitls will lso e le to ess their detil pges whih inlude onfidentil soring informtion. Lstly, the dshord will inlude link to the CPOE Evlution Tool (for dult hospitls only) nd link to the CPOE Evlution Tool sore one the Tool hs een sumitted. 3. New Survey Tool: Lepfrog hs upgrded the survey pltform nd enhned the user experiene through omplete re-design tht inludes n uto sve feture (to redue the onfusion etween sving nd sumitting survey ) s well s new questions lyouts nd setion-level nvigtion. To provide puli omment, plese respond y ompleting the puli omment form loted here. Comments will e epted until COB Deemer 22, 2015. Thnk you for your interest in the Lepfrog Hospitl Survey. 8

APPENDIX I ICD-10 Codes nd Updted Reporting Periods for the 2016 Lepfrog Hospitl Survey for Setion 4 Mternity Cre nd Setion 7 Mnging Serious Errors Bkground As of Otoer 1 st, 2015, ll providers/entities overed y the Helth Insurne Portility nd Aountility At re required to omply with the implementtion of ICD-10 for medil oding, s indited in finl rule estlished in Jnury of 2009 y the U.S. Deprtment of Helth nd Humn Servies (DHHS). Aording to regultions, oded servies provided on or fter Otoer 1 st, 2015 must e oded using ICD-10. Code servies provided efore Otoer 1 st, 2015 must e oded using ICD-9. Reporting Periods Given the implementtion dte of Otoer 1 st, Lepfrog hs djusted the reporting periods for those mesures tht require ICD dignosis or proedure odes. The reporting periods for seleted mesures will e 9-months s speified elow: Jnury 1, 2015 Septemer 30, 2015, for surveys sumitted prior to Septemer 1, 2016 (will use ICD-9 odes); Otoer 1, 2015 June 30, 2016 for surveys (re)sumitted on or fter Septemer 1, 2016 (will use ICD-10 odes) 9

SECTION 4 MATERNITY CARE REFERENCE INFORMATION The following Mternity Cre mesures will require the use of 9-month reporting period nd ICD-10 odes if surveys re (re)sumitted on or fter Septemer 1, 2016: Mternity Cre Volume Erly Eletive Deliveries (PC-01) NTSV Cesren Setion (PC-02) Inidene of Episiotomy DVT Prophylxis in Women Undergoing Cesren Setion High-risk Neworn Deliveries (inluding PC-03) MATERNITY CARE VOLUME Use the following mesure speifitions for surveys sumitted on or fter Septemer 1, 2016. Totl Live Births Soure: The Lepfrog Group Reporting Time Period: Otoer 1, 2015 June 30, 2016 for surveys (re)sumitted on or fter Septemer 1, 2016 Question 3: The numer of live irths t this hospitl lotion, reported to your stte during the reporting time period. Alterntively, the elow list of Z odes n e used to identify live irths, with the ution tht these odes re oded for the neworn, not the mother; likely to e found in your hospitl s irth CIS/medil reord system; ut often not in lims dt sine norml neworn re my e inluded in the mother s lim without y s dignosis oding. Z38.00 Z38.01: Single liveorn infnt, orn in hospitl Z38.30 Z38.31: Twin liveorn infnt, orn in hospitl Z38.61 Z38.69: Other multiple liveorn infnt, orn in hospitl Note: This dt point is simply used to qulify hospitl for further reporting of the norml delivery mesures. 10

EARLY ELECTIVE DELIVERIES Use the following mesure speifitions for surveys sumitted on or fter Septemer 1, 2016. Note on Chnges: Note 1: Mesure speifitions for identifying the denomintor for Erly Eletive Deliveries is now using ICD proedure odes tht indite delivery (previously the denomintor speifitions used ICD dignosti odes tht indited pregnny). Note 2: The exlusion riterion for the denomintor for gesttionl ge now inludes the exlusion of ses where the gesttionl ge is unle to determine. Note 3: the mesure speifition for identifying the numertor for erly eletive deliveries no longer inludes the inlusion riterion for esren irths where the ptient is not experiening spontneous rupture of memrnes. Other Notes: Note 1: Erly Eletive Deliveries n e reported sed on ll eligile ses OR suffiient smple of ses s outlined in the denomintor speifitions. Note 2: Lepfrog uses the speifitions reted y The Joint Commission (TCJ) for the Eletive Delivery Prior to 39 Weeks mesure. As suh, Lepfrog will updte its instrutions nnully, nd more frequently if pproprite, to mintin lignment with TJC. Hospitls n ess TJC s mesure speifitions diretly t: https://mnul.jointommission.org/releses/tjc2015b1/mif0166.html. Eletive Delivery At or After 37 Completed Weeks or Prior to 39 Completed Weeks of Gesttion Soure: The Joint Commission (PC-01) v.2015b1 Reporting Time Period: Otoer 1, 2015 June 30, 2016 for surveys (re)sumitted on or fter Septemer 1, 2016 If you mesured this qulity inditor, reported the results to TJC, nd ontinue to sumit these dt to The Joint Commission, use those dt when responding to this susetion of the survey. Otherwise, use TJC s PC-01 Eletive Delivery mesure speifitions (version 2015B1) to retrospetively ollet nd report dt for this mesure. The PC-01 mesure speifitions re outlined elow. To ess the mesure speifitions diretly on The Joint Commission s wesite, visit https://mnul.jointommission.org/releses/tjc2015b1/mif0166.html. Smpling Cses: Hospitls tht report the Perintl Cre Mesure Set to TJC my use the smpling methodology used y the TJC to report on these questions. 11

Hospitls opting to identify suffiient smple of mothers for this mesure, in lieu of full se reporting, should follow these instrutions: Review your hospitl s first delivery s of Otoer 15, 2015. Evlute this se ginst the inlusion riteri; retin the se for the smple if the delivery ws t or fter 259 dys gesttion (37 ompleted weeks gesttion) nd efore 273 dys gesttion (39 ompleted weeks gesttion). Evlute this se ginst the exlusion riteri; retin the se for the smple if it does not meet ny of the listed exlusions. Move to the next delivery nd evlute for inlusion/exlusion ppliility. Continue through ses in sequentil order until smple of t lest 100 ses is rehed, or ll ses in the reporting period re reviewed, whihever omes first. Question 2 (denomintor): Ptients delivering neworns with >= 37 nd < 39 weeks of gesttion ompleted with Exluded Popultions removed. Inluded Popultions: ICD-10-PCS Prinipl Proedure Code or ICD-10-PCS Other Proedure Codes for delivery s defined in Appendix A, Tle 11.01.1. ICD-10-CM Prinipl Dignosis Code or ICD-10-CM Other Dignosis Codes for plnned esren irth in lor s defined in Appendix A, Tle 11.06.1. Exluded Popultions: Less thn 8 yers of ge or greter thn or equl to 65 yers of ge Length of sty > 120 dys Enrolled in linil trils Gesttionl Age < 37 or >= 39 weeks or Unle to Determine (UTD) Exlude ny ses with one or more of the following ICD-10-CM Prinipl Dignosis Codes or ICD-10-CM Other Dignosis Codes for onditions possily justifying eletive delivery prior to 39 weeks gesttion, s defined in Appendix A, Tle 11.07 (Note: ICD-10-CM ode must e oded) If fewer thn 10 ses during the reporting period, skip the next question. Dt Elements Needed to Report on the Mesure: Admission Dte Birthdte Clinil Tril Dishrge Dte Gesttionl Age ICD-10-PCS Other Proedure Codes ICD-10-PCS Prinipl Proedure Code ICD-10-CM Other Dignosis Codes ICD-10-CM Prinipl Dignosis Code 12

Question 3 (numertor): Ptients with eletive deliveries inluded in the denomintor Inluded Popultions: ICD-10-PCS Prinipl Proedure Code or ICD-10-PCS Other Proedure Codes for one or more of the following: Medil indution of lor s defined in Appendix A, Tle 11.05 while not in Lor prior to the proedure Cesren irth s defined in Appendix A, Tle 11.06 nd ll of the following: not in Lor no history of Prior Uterine Surgery Exluded Popultions: None Dt Elements Needed to Report on the Mesure: ICD-10-PCS Other Proedure Codes ICD-10-PCS Prinipl Proedure Code Lor Prior Uterine Surgery 13

CESAREAN SECTIONS Use the following mesure speifitions for surveys sumitted on or fter Septemer 1, 2016. Note on Chnges: Note 1: Mesure speifitions for identifying the denomintor for NTSV Cesren Setions is now using ICD proedure odes tht indite delivery (previously the denomintor speifitions used ICD dignosti odes tht indited pregnny). Note 2: The exlusion riterion for the denomintor for gesttionl ge now inludes the exlusion of ses where the gesttionl ge is unle to determine. Other Notes: Note 1: NTSV Cesren Setions n e reported sed on ll eligile ses OR suffiient smple of ses s outlined in the denomintor speifitions. Note 2: Lepfrog uses the speifitions reted y The Joint Commission for the NTSV Cesren Setions mesure. As suh, Lepfrog will updte its instrutions nnully, nd more frequently if pproprite, to mintin lignment with the Joint Commission. Hospitls n ess the Joint Commission s mesure speifitions diretly t https://mnul.jointommission.org/releses/tjc2015b1/mif0167.html. Cesren Setions Soure: Joint Commission PC-02 (version 2015B1) Reporting Time Period: Otoer 1st, 2015 June 30, 2016 for surveys (re)sumitted on or fter Septemer 1, 2016 If you mesured this qulity inditor, reported the results to The Joint Commission, nd ontinue to sumit these dt to The Joint Commission, use those dt when responding to this susetion of the survey. Otherwise, use The Joint Commission s PC-02 Cesren Setion mesure speifitions (version 2015B1) to retrospetively ollet nd report dt for this mesure. The PC-02 mesure speifitions re outlined elow. To ess the mesure speifitions diretly on The Joint Commission s wesite, visit https://mnul.jointommission.org/releses/tjc2015b1/mif0167.html. Smpling Cses: Hospitls tht report the Perintl Cre Mesure Set to TJC my use the smpling methodology used y the TJC to report on these questions. Hospitls opting to identify suffiient smple of mothers for this mesure, in lieu of full se reporting, should follow these instrutions: 14

Review your hospitl s first delivery s of Otoer 15, 2015. Evlute this se ginst the inlusion riteri; retin the se for the smple if the delivery ws t or fter 259 dys gesttion (37 ompleted weeks gesttion) nd efore 273 dys gesttion (39 ompleted weeks gesttion). Evlute this se ginst the exlusion riteri; retin the se for the smple if it does not meet ny of the listed exlusions. Move to the next delivery nd evlute for inlusion/exlusion ppliility. Continue through ses in sequentil order until smple of t lest 100 ses is rehed, or ll ses in the reporting period re reviewed, whihever omes first. Question 2 (denomintor): Nulliprous ptients delivered of live term singleton neworn in vertex presenttion. Inluded Popultions: ICD-10-PCS Prinipl Proedure Code or ICD-10-PCS Other Proedure Codes for delivery s defined in Appendix A, Tle 11.01.1. Nulliprous ptients with ICD-10-CM PRINCIPAL DIAGNOSIS CODE OR ICD-10-CM OTHER DIAGNOSIS CODES for outome of delivery s defined in Appendix A, Tle 11.08, nd with delivery of neworn with 37 weeks or more of gesttion ompleted. Exluded Popultions: ICD-10-CM PRINCIPAL DIAGNOSIS CODE OR ICD-10-CM OTHER DIAGNOSIS CODES for multiple gesttions nd other presenttions s defined in Appendix A, Tle 11.09 Less thn 8 yers of ge or greter thn or equl to 65 yers of ge Length of sty >120 dys Enrolled in linil trils Gesttionl Age < 37 weeks or Unle to Determine (UTD) If fewer thn 10 ses during the reporting period, skip the next question. Dt Elements Needed to Report on the Mesure: Admission Dte Birthdte Clinil Tril Dishrge Dte Gesttionl Age ICD-10-PCS Other Proedure Codes ICD-10-PCS Prinipl Proedure Code ICD-10-CM Other Dignosis Codes ICD-10-CM Prinipl Dignosis Codes Numer of Previous Live Births 15

Question 3 (numertor): Ptients in the denomintor with esren irths. Inluded Popultions: ICD-10-PCS PRINCIPAL PROCEDURE CODE OR ICD-10-PCS OTHER PROCEDURE CODES for esren irth s defined in Appendix A, Tle 11.06 Exluded Popultions: None Dt Elements Needed to Report on the Mesure: ICD-10-PCS Other Proedure Codes ICD-10-PCS Prinipl Proedure Code 16

EPISIOTOMY Use the following mesure speifitions for surveys sumitted on or fter Septemer 1, 2016. Inidene of Episiotomy in Vginl Deliveries Soure: Ntionl Qulity Forum #0470 Reporting Time Period: Otoer 1st, 2015 June 30, 2016 for surveys (re)sumitted on or fter Septemer 1, 2016 Question 2 (denomintor): Totl numer of vginl deliveries during the reporting period with Exluded Popultions removed. For the purposes of this mesure, use the following MS-DRGs to identify vginl delivery: 767: Vginl delivery with steriliztion nd/or D&C 768: Vginl delivery with O.R. proedure exept steriliztion nd/or D&C 774: Vginl delivery with ompliting dignoses 775: Vginl delivery without ompliting dignoses Exluded Popultions: Exlude ny ses with the following ICD-10-CM dignosti ode in primry or seondry field: O66.0: Ostruted lor due to shoulder dystoi Question 3 (numertor): Numer of ses inluded in the denomintor tht hd n episiotomy proedure performed. For purposes of this mesure, the following ICD-10-PCS proedure odes should e used for identifying n episiotomy: 0W8NXZZ: Division of femle perineum, externl pproh 0WQNXZZ: Repir femle perineum, externl pproh 10D07Z3: Extrtion of produts of oneption, low foreps, vi nturl or rtifiil opening 10D07Z4: Extrtion of produts of oneption, mid foreps, vi nturl or rtifiil opening 10D07Z5: Extrtion of produts of oneption, high foreps, vi nturl or rtifiil opening 10D07Z6: Extrtion of produts of oneption, vuum, vi nturl or rtifiil opening 17

MATERNITY CARE PROCESS MEASURE SPECIFICATIONS Use the following mesure speifitions for surveys sumitted on or fter Septemer 1, 2016. APPROPRIATE DVT PROPHYLAXIS IN WOMEN UNDERGOING CESAREAN DELIVERY Soure: Ntionl Qulity Forum #0473 Reporting Time Period: Otoer 1st, 2015 June 30, 2016 for surveys (re)sumitted on or fter Septemer 1, 2016 Questions 3 (denomintor): Eligile ses inlude ll women undergoing esren delivery during the reporting period. Inlude ses with one of the following MS-DRG odes: 765: Cesren setion w CC/MCC 766: Cesren setion w/o CC/MCC Exluded Popultions: None. Question 3 (numertor): Numer of eligile ses inluded in denomintor who reeived either frtionted or unfrtionted heprin or heprinoid, or pneumti ompression devies prior to surgery. 18

HIGH-RISK DELIVERIES MEASURE SPECIFICATIONS Use the following mesure speifitions for surveys sumitted on or fter Septemer 1, 2016. HIGH RISK DELIVERIES VOLUME STANDARD Soure: The Lepfrog Group Reporting Time Period: Otoer 1st, 2015 June 30, 2016 for surveys (re)sumitted on or fter Septemer 1, 2016 Question 5 (instrutions for volume reporting): numer of very-low irth-weight ies dmitted to your hospitl s neontl intensive re unit(s) during the reporting period. Importnt Note: Do not use volume odes for mesuring nd reporting the proess mesure; use the seprte speifitions for tht inditor. Ptient popultions used for the proess mesure my DIFFER from ptient popultions inluded here in the volume ounts. Use only ICD-10-CM Dignosis Codes s indited in the speifitions when lulting hospitl volume for the numer of very-low irth-weight ies (VLBWB) your hospitl treted. These ICD-10 CM Dignosis Codes should e used only to identify the numer of VLBWB for question #5. The ount n inlude inorn s well s trnsfer ses. Numer of neworns dmitted to the NICU with the following ICD-10 CM Dignosis Codes: P05.02 P05.05: Neworn light for gesttionl ge, 500-1499 grms P05.12 P05.15: Neworn smll for gesttionl ge, 500-1499 grms P05.2: Neworn ffeted y fetl (intruterine) mlnutrition not light or smll for gesttionl ge P05.9: Neworn ffeted y slow intruterine growth, unspeified P07.02 P07.03: Extremely low irth weight neworn, 500-999 grms P07.14 P07.15: Other low irth weight neworn, 1000-1499 grms Exluded Popultions: None. * Hospitls opting to report on Outome (Deth or Moridity) insted of Volume, y providing dt from their Vermont Oxford Network (VON) report in question #6-11 will not need to use ICD-10 oding. Insted, they will report dt diretly from VON using the sme methodology s in prior survey yers. 19

HIGH-RISK DELIVERIES PROCESS MEASURE SPECIFICATIONS Use the following mesure speifitions for surveys sumitted on or fter Septemer 1, 2016. Note on Chnges: Note 1: The Joint Commission hs updted the gesttionl ge inlusion riterion for the denomintor to >= 24 nd <34 weeks gesttion ompleted (previously the denomintor speifitions inluded ptients delivering live preterm neworns with >= 24 nd <32 weeks gesttion ompleted). Note 2: Mesure speifitions for identifying the denomintor for ntentl steroids is now using ICD proedure odes tht indite delivery (previously the denomintor speifitions used ICD dignosti odes tht indited pregnny). Note 3: The exlusion riterion for the denomintor for gesttionl ge now inludes the exlusion of ses where the gesttionl ge is unle to determine. ANTENATAL STEROIDS Soure: Vermont Oxford Network (see Mnul of Opertions) or The Joint Commission (see PC-03 version 2015B1) If you prtiipte in the Vermont Oxford Network, mesured dherene to this proess-of-re qulity inditor, reported the results to VON, nd ontinue to sumit these dt to VON, then use those dt when responding to this susetion of survey, nd ignore The Joint Commission (TJC) speifitions listed elow for the mesure. If you prtiipte with The Joint Commission, mesured dherene to this proess-of-re qulity inditor, reported the results to The Joint Commission, nd ontinue to sumit these dt to The Joint Commission, use those dt when responding to this susetion of the survey. Otherwise, use The Joint Commission s PC-03 Antentl Steroids mesure speifitions (version 2015B1) detiled elow to retrospetively ollet nd report dt for this mesure. To ess the mesure speifitions diretly on The Joint Commission s wesite, visit https://mnul.jointommission.org/releses/tjc2015b1/mif0168.html. Smpling Cses: Hospitls tht report the Perintl Cre Mesure Set to TJC my use the smpling methodology used y the TJC to report on these questions. Otherwise, hospitls with suffiient smple size (s defined in endnote 24), n rndomly smple for the denomintor of eh inditor, nd mesure nd report dherene sed on tht smple. Most likely the numertor riteri for this mesure will require medil hrt review if these speifi dt re not lredy extrted or oded onsistently for other purposes. Question 16 (denomintor) Ptients delivering live preterm neworns with >=24 nd <34 weeks gesttion ompleted. 20

Inluded Popultions: ICD-10-PCS Prinipl Proedure Code or ICD-10-PCS Other Proedure Codes for delivery s defined in Appendix A, Tle 11.01.1. Exluded Popultions: Less thn 8 yers of ge or greter thn or equl to 65 yers of ge Length of Sty >120 dys Enrolled in linil trils Doumented Reson for Not Inititing Antentl Steroids ICD-10-CM Prinipl Dignosis Code or ICD-10-CM Other Dignosis Codes for fetl demise s defined in Appendix A, Tle 11.09.1 Gesttionl Age < 24 or >= 34 weeks or Unle to Determine (UTD) Dt Elements Needed to Report on the Mesure: Admission Dte Birthdte Clinil Tril Dishrge Dte Gesttionl Age ICD-10-CM Other Dignosis Codes ICD-10-CM Prinipl Dignosis Code Reson for Not Inititing Antentl Steroids Question 17 (numertor): The numer of ptients inluded in the denomintor with ntentl steroids initited prior to delivering preterm neworns (>=24 nd <34 weeks gesttion ompleted). Inluded Popultions: Antentl steroids initited (refer to Appendix C, Tle 11.0, ntentl steroid meditions) Exluded Popultions: None. Dte Elements Needed to Report on the Mesure: Antentl Steroids Initited 21

SECTION 7 MANAGING SERIOUS ERRORS REFERENCE INFORMATION The following mesures from Setion 7 Mnging Serious Errors will require the use of 9-month reporting period nd ICD-10 odes if surveys re (re)sumitted on or fter Septemer 1, 2016: Hospitl-Aquired Pressure Ulers Hospitl-Aquired Injuries These mesures do not pply to peditri hospitls. PRESSURE ULCERS MEASURE SPECIFICATIONS Use the following mesure speifitions for surveys sumitted on or fter Septemer 1, 2016. HAC - Rte of Stge III/IV Pressure Ulers Soure: The Lepfrog Group Reporting Time Period: Otoer 1, 2015 June 30, 2016 for surveys (re)sumitted on or fter Septemer 1, 2016 Q.3 Denomintor: Totl dult (ges 18 nd older) inptient dishrges (inluding deths) during the reporting time period. [Note: Hospitls should inlude in the denomintor ny ptient for whih they ode present-on-dmission (POA). This would inlude most short-sty psyh nd reh ptients.] Q.4 Numertor: Numer of eligile ses inluded in the denomintor with ny of the following ICD-10 dignosis odes for stge III nd IV pressure ulers s seondry dignosis (dignosis 2-9 on lim), with Present-on-Admission (POA) inditor of N or U, s defined in CMS Appendix I Hospitl Aquired Conditions (HAC) List for HAC 04: Stge III nd IV Pressure Ulers Seondry Dignosis (see pge 1). 22

INJURIES MEASURE SPECIFICATIONS Use the following mesure speifitions for surveys sumitted on or fter Septemer 1, 2016. HAC - Rte of Hospitl-Aquired Injuries Soure: The Lepfrog Group Reporting Time Period: Otoer 1st, 2015 June 30, 2016 for surveys (re)sumitted on or fter Septemer 1, 2016 Q.3 Denomintor: Totl dult (ges 18 nd older) inptient dishrges (inluding deths) during the reporting time period. [Note: Hospitls should inlude in the denomintor ny ptient for whih they ode present-on-dmission (POA). This would inlude most short-sty psyh nd reh ptients.] Q.5 Numertor: Numer of eligile ses inluded in the denomintor with ny of the following ICD-10 dignosis odes for flls nd trum s seondry dignosis (dignosis 2-9 on lim), with Present-on-Admission (POA) inditor of N or U, s defined in CMS Appendix I Hospitl Aquired Conditions (HAC) List for HAC 05: Flls nd Trum Seondry Dignosis (see pge 1-10). 23

APPENDIX II Guidelines for Culture of Sfety Survey tht Demonstrtes Vlidity, Consisteny, nd Reliility For the purposes of reporting on Sfe Prtie 2 Culture Mesurement, Feedk, nd Intervention, hospitls must ondut ulture of sfety survey of their employees (the units surveyed must ount for t lest 50% of the ggregted re delivered to ptients within the fility, nd inludes the high ptient sfety risk units or deprtments) using ntionlly reognized tool tht hs demonstrted vlidity, onsisteny nd reliility within the pst 24 months. There re numerous ntionlly-reognized ulture of sfety survey tools tht hve demonstrted vlidity, onsisteny, nd reliility in peerreviewed literture. However, some hospitls hve stted these ulture surveys do not meet their needs. These hospitls often hoose to rete their own surveys. In onsulttion with Lepfrog s Culture of Sfety Expert Pnel, we hve developed set of guidelines for wht onstitutes vlid, onsistent, nd relile survey tool for the purposes of reporting on Sfe Prtie 2 on the Lepfrog Hospitl Survey. The Lepfrog Culture of Sfety Expert Pnel hs developed hierrhy for survey ontent: Tier 1 (Most Preferred): Unltered, ntionlly-reognized tool with informtion on the vlidity, onsisteny, nd reliility of the tool pulished in peer-reviewed literture (i.e. AHRQ Hospitl Survey on Ptient Sfety Culture, Sfety Attitudes Questionnire, Ptient Sfety Climte for Helthre Orgniztions, Zohr). Tier 2: Minor modifitions to Tier 1 tool, suh s simple word hnges tht do not lter the intent or tone of questions (e.g., hnging unit to deprtment ). However, the survey is utilized in its entirety. Tier 3 (Lest Preferred): Mjor modifitions to n estlished tool or development of self-reted tool (e.g., rewording questions from Tier 1 tool from negtive to positive, employee enggement surveys tht inlude some questions relted to ulture of sfety, et.) Hospitls tht use Tier 3 survey (s desried ove), must ensure tht the tool demonstrtes similr psyhometri properties to Tier 1 survey for the purposes of reporting on Sfe Prtie 2 Culture Mesurement, Feedk, nd Intervention on the Lepfrog Hospitl Survey. Hospitls tht use Tier 3 survey my e sked to provide doumenttion tht the tool hs een ssessed for vlidity, onsisteny, nd reliility. To stisfy this requirement, hospitls must doument tht the tool demonstrtes three of the four following qulities: 1. Sle reliility. One ommon ssessment of reliility is Cronh s Alph, sttistil index of internl onsisteny tht lso provides n estimte of the rtio of true sore to error in Clssil Test Theory. 2. Explortory/onfirmtory ftor nlysis (this qulity is required if reting new domin or omposite sores). Explortory Ftor Anlysis (EFA) is tehnique whose overrhing gol is to identify the underlying reltionships etween mesured vriles. EFA is ommonly used y reserhers when developing sle nd serves to identify set of ltent onstruts underlying ttery of mesured vriles. Confirmtory ftor nlysis (CFA) is used to test whether mesures of onstrut re onsistent with reserher's understnding of the nture of tht onstrut. The ojetive of CFA is to test whether the dt fit hypothesized mesurement model. 24

3. The tool ws ssessed nd shown to e vlid, whih ould inlude: Convergent/divergent vlidity. To estlish onvergent vlidity, one needs to show tht mesures tht should e relted re in relity relted. To estlish disriminnt vlidity, one needs to show tht mesures tht should not e relted re in relity not relted. Both of these re ommonly demonstrted y exmining the item interorreltions for ll item pirings. Preditive vlidity. Preditive vlidity is the extent to whih sore on sle predits sores on some riterion. As n exmple, the preditive vlidity of ulture of sfety sle would e demonstrted y exmining the orreltion etween unit s sore on the sle (t point in time) nd rtes of preventle hrm in the unit (t future point in time). Fe vlidity. Fe vlidity is mesure of how representtive sle or tool is 't fe vlue,' nd whether it ppers to e good sle/tool. On mesure of hppiness, for exmple, the test would e sid to hve fe vlidity if it ppered to tully mesure levels of hppiness. Fe vlidity only mens tht the test looks like it works; it does not men tht the test hs een proven to work. 4. The tool underwent ognitive testing. Dt from ognitive interviews re qulittive, nd nlysis of this dt n identify soures of response error s well s vrious interprettions of questions. By onduting omprtive nlysis of the ognitive interviews, it is possile to identify ptterns of error nd misinterprettion ross groups of people. For more omplete understnding of these onepts, plese see the following rtiles: Sexton JB, Helmreih RL, Neilnds TB, Rown K, Vell K, Boyden J, et l. The Sfety Attitudes Questionnire: psyhometri properties, enhmrking dt, nd emerging reserh. BMC Helth Servies Reserh. 2006;6:44. Singer SJ, Meterko M, Bker L, G G, Flwell A, nd Rosen A. Workfore pereptions of hospitl sfety ulture: Development nd vlidtion of the Ptient Sfety Climte in Helthre Orgniztions survey. Helth Servies Reserh. 2007;42(5):1999. Sorr J nd Dyer N. Multilevel psyhometri properties of the AHRQ hospitl survey on ptient sfety ulture. BMC Helth Servies Reserh. 2010;10:199 While the Expert Pnel did not identify speifi domins or questions tht need to e inluded to e onsidered ulture of sfety survey, Tier 3 survey tools need to e grounded in n underlying theory of the orgniztion s ulture. The tool developers must estlish why they inluded the questions nd domins in the survey to support the theory of ulture. The following guidelines should e onsidered for survey dministrtion: Employees ompleting the survey should hve fmilirity with the fility (i.e., not employees who rrely work in the fility). The survey should e dministered to, t lest, the frontline linil stff nd ledership. The survey should e dministered in wy tht voids oerion. The survey s smple popultion should e representtive of the fility s linil nd dministrtive workfore. High response rtes re onsidered more importnt thn high survey sores. 25

APPENDIX III Questions from the NHSN Annul Hospitl Survey on Antimiroil Stewrdship Questions 1. Does your fility hve written sttement of support from ledership tht supports efforts to improve ntiioti use (ntiioti stewrdship)? 2. Is there leder responsile for outomes of stewrdship tivities t your fility? 2. If yes, wht is the position of this leder: (hek one) Physiin Phrmist Other (plese speify): 3. Is there t lest one phrmist responsile for improving ntiioti use t your fility? 4. Does your fility provide ny slry support for dedited time for ntiioti stewrdship tivities? 5. Does your fility hve poliy tht requires presriers to doument n indition for ll ntiiotis in the medil reord or during order entry? 6. Does your fility hve fility-speifi tretment reommendtions, sed on ntionl guidelines nd lol suseptiility, to ssist with ntiioti seletion for ommon linil onditions? 7. Is there forml proedure for ll liniins to review the ppropriteness of ll ntiiotis t or fter 48 hours from the initil orders (e.g. ntiioti time out)? 8. Do ny speified ntiioti gents need to e pproved y physiin or phrmist prior to dispensing t your fility? 9. Does physiin or phrmist review ourses of therpy for speified ntiioti gents nd ommunite results with presriers (i.e., udit with feedk) t your fility? 10. Does your fility monitor ntiioti use (onsumption) t the unit, servie, nd/or fility wide? 11. Do presriers ever reeive feedk y the stewrdship progrm out how they n improve their ntiioti presriing? 12. Hs your stewrdship progrm provided edution to liniins nd other relevnt stff on improving ntiioti use? 26

APPENDIX IV Detiled Wording Chnges nd Additions/Deletions for Setion 6 NQF Sfe Prties PRACTICE #1 CULTURE OF SAFETY LEADERSHIP STRUCTURES AND SYSTEMS (pge numers referene NQF Sfe Prties for Better Helthre 2010 Updte report) 2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 1.1 In regrd to rising the wreness of key stkeholders to our orgniztion s efforts to improve ptient sfety, the following tions relted to identifition nd mitigtion of risk nd hzrds hve een tken: Bord (governne) minutes for the pst 12 months reflet regulr ommunition regrding ll three of the following: risks nd hzrds (s defined y Sfe Prtie #4, Identifition nd Mitigtion of Risks nd Hzrds); ulture mesurement (s defined y Sfe Prtie #2, Culture Mesurement, Feedk, nd Intervention); nd, progress towrds resolution of sfety nd qulity prolems. (p.75) Ptients (who re not employed y the orgniztion) nd fmily of ptients re forml prtiipnts in sfety nd qulity ommittees tht meet on regulrly sheduled sis. (p.75) Ptients (who re not employed y the orgniztion) nd fmily of ptients re tive prtiipnts in sfety nd qulity ommittees tht meet on regulrly sheduled sis. (p.75) 27

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording steps hve een tken to report to the ommunity in the lst 12 months of ongoing efforts to improve sfety nd qulity in the orgniztion nd the results of these efforts. (p.75) d ll stff nd independent prtitioners were mde wre in the pst 12 months of ongoing efforts to redue risks nd hzrds nd to improve ptient sfety nd qulity in the orgniztion. (p.75) d 1.2 In regrd to holding the Bord, senior mngement, mid-level mngement, physiin ledership, nd frontline regivers diretly ountle for results relted to mitigting unsfe prties, the orgniztion hs done the following: In regrd to holding the Bord, senior mngement, mid-level mngement, physiin ledership, nd frontline regivers diretly ountle for results relted to identifying nd reduing unsfe prties, the orgniztion hs done the following: n integrted, ptient sfety progrm hs een in ple for t lest the pst 12 months providing oversight nd lignment of sfe prtie tivities. (p.76) ptient sfety offier (PSO) hs een ppointed nd ommunites regulrly with the Bord (governne) nd senior dministrtive ledership; the PSO is the primry point of ontt of the integrted, ptient sfety progrm. (p.76) performne hs een doumented in performne reviews nd/or ompenstion inentives for ll levels of hospitl mngement nd hospitlemployed regivers noted ove. (p.76) 28

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording d the interdisiplinry ptient sfety tem ommunited regulrly with mngement regrding ll three of the following: d root use nlyses (s defined y Sfe Prtie #4, Culture Mesurement, Feedk, nd Intervention); progress in meeting sfety gols; nd, providing tem trining to regivers (s defined y Sfe Prtie #3, Temwork Trining nd Skill Building); nd, doumented these ommunitions in meeting minutes. (pp.76-77) e the fility reported dverse events to externl mndtory or voluntry progrms. (p.77) 1.3 In regrd to implementtion of the ptient sfety progrm, the Bord (governne) nd senior dministrtive leders hve provided resoures to over the implementtion during the lst 12 months, nd: dedited ptient sfety progrm udgets support the progrm, stffing, nd tehnology investment. (p.77) doumenttion of these udgets is ville for review y externl orgniztions. (p.77) Removed in 2016 29

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 1.4 Strutures nd systems for ssuring tht ledership is tking diret nd speifi tions hve een in ple for the pst 12 months, s evidened y: CEO nd senior dministrtive leders re personlly engged in reinforing ptient sfety improvements, e.g., wlk-rounds, holding ptient sfety meetings, reporting to the Bord (governne). Clendrs reflet lloted time. (p.78) CEO hs tively engged unit, servie-line, deprtmentl nd mid-level mngement leders in ptient sfety improvement tions. (p.79) hospitl hs estlished struture for input into the ptient sfety progrm y independent medil prtitioners nd medil ledership. Input doumented in meeting minutes or mterils. (p.79) hospitl hs estlished struture for input into the ptient sfety progrm y liensed independent prtitioners nd the orgnized medil stff nd medil ledership. Input doumented in meeting minutes or mterils. (p.79) 30

PRACTICE #2 CULTURE MEASUREMENT, FEEDBACK, AND INTERVENTION (pge numers referene NQF Sfe Prties for Better Helthre 2010 Updte report) 2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 2.1 In regrd to Culture Mesurement, our orgniztion hs done the following within the lst 24 months: onduted ulture of sfety survey of our employees using ntionlly reognized tool tht hs demonstrted vlidity, onsisteny nd reliility. The units surveyed ount for t lest 50% of the ggregted re delivered to ptients within the fility, nd inludes the high ptient sfety risk units or deprtments.(p.88) If this item is not heked, no other items in this Prtie #2 my e heked. portryed the results of the ulture survey in report, whih reflets oth hospitl-wide nd individul unit level results. (p.88) portryed the results of the ulture survey in report, whih reflets oth hospitl-wide nd individul unit level results, s pplile. (p.88) New in 2016 enhmrked results of the ulture survey ginst externl orgniztions, suh s like hospitls or other hospitls within the sme helth system. 31

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording d New in 2016 ompred results of the ulture survey ross internl work groups, roles, nd stff levels. e New in 2016 used results of the ulture survey to derief t the relevnt unit level, using semi-strutured pprohes for the deriefings nd presenting results in ggregte form to ensure the nonymity of survey respondents. 2.2 In regrd to ountility for improvements in the mesurement of the ulture of sfety, our orgniztion hs done the following within the lst 24 months: involved senior dministrtive ledership in the identifition nd seletion of smpled units; nd, in the seletion of n pproprite tool for mesuring the ulture of sfety. (p.88) shred the results of the ulture mesurement survey with the Bord (governne) nd senior dministrtive ledership in forml report nd disussion. (p.88) 32

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording New in 2016 performne evlution riteri for senior dministrtive leders inluded oth response rtes to the survey nd the use of survey results in improvement efforts. 2.3 In regrd to the ulture of sfety mesurement, the orgniztion hs done the following (or hs hd the following in ple) within the lst 12 months: onduted stff edution progrm(s) on methods to improve the ulture of sfety, or onduted tem trining development progrms, sed on survey results. Trining ws doumented in personnel or other dministrtive reords. (p.89) onduted stff edution progrm(s) on methods to improve or sustin the ulture of sfety, tilored to the orgniztion s survey results. (p.89) inluded the osts of nnul ulture mesurement/follow-up tivities in the ptient sfety progrm udget. (p.88) 2.4 In regrd to ulture mesurement, feedk, nd interventions, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: 33

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording developed or implemented expliit, hospitl-wide orgniztionl poliies nd proedures for regulr ulture mesurement (p.88) OR implemented strtegies for improving ulture sed on survey results. (p.88) disseminted the results of the survey widely ross the institution, with follow-up meetings held y senior dministrtive ledership with the smpled units. (p.88) identified performne improvement interventions sed on the survey results, whih were shred with senior dministrtive ledership nd susequently mesured nd monitored. (p.88) 34

PRACTICE #3 TEAMWORK TRAINING AND SKILL BUILDING (pge numers referene NQF Sfe Prties for Better Helthre 2010 Updte report) 2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 3.1 In regrd to temwork trining nd skill uilding, our orgniztion hs done the following within the lst 12 months: onduted literture review of the temwork trining impt in helthre or in other settings. (p.101) onduted literture review of temwork trining in helthre or other settings nd hve identified est prties. OR OR onduted review of ville temwork trining progrms in progressive orgniztions. (p.99) onduted review of ville temwork trining progrms in progressive orgniztions to identify est prties. (p.99) onduted n ssessment of high ptient sfety risk res y n Interdisiplinry Ptient Sfety Tem to determine speifi proesses in need of temwork improvement. Those proesses were identified to senior dministrtive ledership. (p.97) onduted n ssessment of high-risk res, in terms of ptient sfety, y n interdisiplinry ptient sfety tem to determine speifi proesses (e.g., ommunition, ollortion) nd those involved in those proesses in need of temwork improvement. Those proesses were identified to senior dministrtive ledership. (p.97) informed senior mngement, mid-level mngement nd physiin ledership out the need for temwork trining, skill uilding, nd identified internl resoures nd possile resoures from progressive orgniztions. (pp.97-98) informed senior mngement, mid-level mngement nd physiin ledership out the need for temwork trining nd skill uilding. 35

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording d ssessed the orgniztionl need for rpid response systems nd ny ssoited trining. (p.97) d informed senior mngement, mid-level mngement nd physiin ledership tht to meet the need, internl resoures nd possile resoures from progressive orgniztions hve een identified. (pp.97-98) e ssessed the orgniztionl need for rpid response systems nd ny ssoited trining. (p.97) 3.2 In regrd to ledership eing held ountle for the demonstrtion of temwork skills in the orgniztion, our orgniztion hs done the following within the lst 12 months:. determined, through literture review or n ssessment, set of trgeted units or servie lines for detiled temwork trining nd effetive temwork skill uilding. These units/lines were identified y the CEO to the Bord (governne), senior mngers, nd medil stff. (p.97) provided si temwork trining to the Bord (governne), senior mngers, medil stff, mid-level mngement, nd frontline nurses on ommunition hnd-offs nd tem filures leding to ptient hrm. Trining ws doumented in personnel or dministrtive reords. (p.96) 3.3 In regrd to effetive temwork trining nd skill uilding, our orgniztion hs done the following within the lst 12 months: 36

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording resoured ptient sfety progrm udgets to support the ssessment of need nd tem trining tivities. provided linil stff nd liensed independent prtitioners in the hospitltrgeted units detiled temwork trining nd skill uilding. Prtiiption ws doumented. (p.96) 3.4 Effetive tem-entered interventions were either in ple or were initited in the pst 12 months, s evidened y: nottion in ord minutes doumenting tht the performne improvement trgets in identified units were eing ddressed. (p.97) evlution or doumenttion of unit or servie line results for tems tht hd reeived the detiled tem trining intervention during the pst 12 months. (pp.97-98) 37

PRACTICE #4 RISKS AND HAZARDS (pge numers referene NQF Sfe Prties for Better Helthre 2010 Updte report) 2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 4.1 Within the lst 12 months our orgniztion hs done the following: ssessed risks nd hzrds to ptients y reviewing retrospetive soures, suh s: ssessed risks nd hzrds to ptients y reviewing multiple retrospetive soures, suh s: serious nd sentinel event reporting; serious nd sentinel event reporting; root use nlyses for dverse events; root use nlyses for dverse events; independent omprtive mortlity nd moridity informtion with the hospitl s performne; independent omprtive mortlity nd moridity informtion with the hospitl s performne; ptient sfety inditors; ptient sfety inditors; trigger tools; trigger tools; hospitl redittion surveys; hospitl redittion surveys; risk mngement nd filed litigtion; risk mngement nd filed litigtion; nonymous internl omplints, inluding omplints of usive nd disruptive regiver ehvior; nd nonymous internl omplints, inluding omplints of usive nd disruptive regiver ehvior; nd omplints filed with stte/federl uthorities; omplints filed with stte/federl uthorities; nd sed on those findings, doumented reommendtions for improvement. (p.105) nd sed on those findings, doumented reommendtions for improvement. (p.105) 38

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording ssessed risks nd hzrds to ptients using prospetive identifition tools: Filure Modes nd Effets Anlysis (FMEA) nd/or Proilisti Risk Assessment, nd hs doumented reommendtions for improvement. (p.106) ssessed risks nd hzrds to ptients using prospetive identifition methods: Filure Modes nd Effets Anlysis (FMEA) nd/or Proilisti Risk Assessment, nd hs doumented reommendtions for improvement. (p.106) defined their risk mitigtion pln sed on their own risk profile s identified in () nd (), nd hs doumented reommendtions for improvement. (p.107) omined results of () nd () to develop their own risk profile nd used tht to identify priorities nd develop risk mitigtion plns. (p.107) d shred results from the two ssessments, noted in (), (), nd the risk mitigtion pln noted in () ove widely ross the orgniztion, from the Bord (governne) to front-line regivers. (p.107) d. This item my not e heked unless ll items 4.1,, re heked. 4.2 Ledership is ountle for identifition of risks, hzrds nd mitigtion efforts in the pst yer, s evidened y: Ledership is ountle for identifition of risks nd hzrds to ptients nd mitigtion efforts in the pst yer, s evidened y: pprovl of n tion pln y the CEO nd the Bord (governne) for undertking the ssessments of risk, hzrds nd for the mitigtion of risk for ptients. (p.106) 39

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording inorportion of the identifition nd mitigtion of risks into performne reviews OR outlined finnil inentives for ledership nd the Ptient Sfety Offier for identifying nd mitigting risks to ptients s identified in the pproved tion pln. 4.3 In regrd to developing the ility to ppropritely ssess risk nd hzrds, the orgniztion hs done the following or hd in ple during the lst 12 months: In regrd to developing the ility to ppropritely ssess risk nd hzrds to ptients, the orgniztion hs done the following or hd in ple during the lst 12 months: resoured ptient sfety progrm udgets suffiiently to support ongoing risk nd hzrd ssessments nd progrms for redution of risk. provided mngers t ll levels with trining on the prospetive identifition tools for monitoring risk in their res; senior mngers hve reeived trining in the integrtion of risk nd hzrd informtion ross the orgniztion. Trining ws doumented. (pp.107-108) provided mngers t ll levels with trining on the prospetive identifition tools for monitoring risk in their res. senior mngers hve reeived trining in the integrtion of risk nd hzrd informtion ross the orgniztion. Trining ws doumented. (pp.107-108) 40

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 4.4 Strutures nd systems for ssuring tht diret nd speifi tions hve tken ple to mitigte risks for the pst 12 months, inlude: Strutures nd systems for ssuring tht diret nd speifi tions hve tken ple to mitigte risks to ptients for the pst 12 months, inlude: provided risk identifition trining to the mngement nd stff in high risk ptient sfety units suh s: emergeny deprtment, lor nd delivery, ICUs, nd operting rooms. (p.106) estlished or lredy hd in ple struture, developed y the CEO nd senior ledership, for gthering ll informtion relted to risks, hzrds nd mitigtion efforts within the orgniztion with input from ll levels of stff within the orgniztion nd from ptients nd their fmilies. (p.110) evidene of high-performne or tions tken for the following five ptient sfety risk res: flls, mlnutrition, pneumti tourniquets, spirtion, nd workfore ftigue (p.108) evidene of high-performne or tions tken for the following four ptient sfety risk res: flls, mlnutrition, spirtion, nd workfore ftigue (p.108) 41

PRACTICE #9 NURSING WORKFORCE (pge numers referene NQF Sfe Prties for Better Helthre 2010 Updte report) Is your hospitl urrently reognized s n Amerin Nurses Credentiling Center (ANCC) Mgnet orgniztion? Yes No If Yes, your hospitl will reeive full redit for this Sfe Prtie nd no oxes need to e heked. If No, plese hek ll of the oxes tht pply. 2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 9.1 In regrd to ensuring dequte nd ompetent nursing stff servie nd nursing ledership t ll levels, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: held t lest one edutionl meeting for liniins, senior mngement, mid-level mngement, nd line mngement speifilly relted to the res of ptient sfety nd dequte nurse stffing effetiveness. (p.155) performed risk ssessment nd n evlution of the frequeny nd severity of dverse events tht n e relted to nurse stffing. (p.155) performed risk ssessment tht inludes n evlution of the frequeny nd severity of dverse events tht n e relted to nurse stffing. (p.155) sumitted report to the Bord (governne) with reommendtions for mesurle improvement trgets. (p.155) 42

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording d olleted nd nlyzed dt of tul unit-speifi nurse stffing levels on qurterly sis to identify nd ddress potentil ptient sfety-relted stffing issues. (p.155) d e provided unit-speifi reports of potentil ptient sfety-relted stffing issues to senior dministrtive ledership nd the Bord (governne) t lest qurterly. (p.155) e 9.2 In regrd to ensuring dequte nd ompetent nursing stff servie nd nursing ledership t ll levels, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: held deprtmentl/linil ledership diretly ountle for improvements in performne through performne reviews or ompenstion. (p.155) inluded senior nursing ledership s prt of the hospitl senior mngement tem. (p.155) reported performne metris relted to this re to the Bord (governne). (p.155) reported performne metris relted to this Sfe Prtie to the Bord (governne). (p.155) d held the Bord (governne) nd senior dministrtive ledership ountle for the provision of finnil resoures to ensure dequte nurse stffing levels. (p.155) d 43

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 9.3 In regrd to ensuring dequte nd ompetent nursing stff servie nd nursing ledership t ll levels, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: onduted stff edution on mintining nd improving ompetenies speifi to ssigned jo duties relted to the sfety of the ptient, with ttendne doumented. (p.155) lloted dedited nd ompensted stff time to redue dverse events relted to stffing levels or ompeteny issues. lloted proteted time for diret re stff nd mngers to redue dverse events relted to stffing levels or ompeteny issues. doumented tul expenses inurred during the pst yer tied to this sfe prtie. doumented expenses inurred during the pst yer tied to qulity improvement efforts round this Sfe Prtie d udgeted finnil resoures for lning stffing levels nd skill levels to improve performne. (p.155) d e governne hs pproved udget for rehing optiml nurse stffing. (p.155) e 9.4 In regrd to ensuring dequte nd ompetent nursing stff servie nd nursing ledership t ll levels, our orgniztion hs done the following within the lst 12 months or hs hd the following in ple during the lst 12 months nd updtes re mde regulrly: 44

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording implemented poliies nd proedures, with input from nurses, to ensure tht dequte nursing stff-to-ptient rtios re hieved. (p.154) implemented stffing pln, with input from nurses, to ensure tht dequte nursing stff-to-ptient rtios re hieved. (p.154) developed poliies nd proedures for effetive stffing trgets tht speify numer, ompeteny nd skill mix of nursing stff. (p.155) implemented performne improvement projet tht minimizes the risk to ptients from less thn optiml stffing levels. (p.155) OR monitored previously implemented hospitl-wide performne improvement progrm tht mesures, nd demonstrtes full hievement of, the impt of this speifi Sfe Prtie. (p.155) d provided unit-speifi reports of potentil ptient sfety-relted stffing issues to senior dministrtive ledership nd the Bord (governne) t lest qurterly. (p.155) d Removed in 2016 e provided reports t lest nnully to the puli on your hospitl s urrent sttus in hieving dequte nd ompetent nurse stffing gols. (p.155) e Removed in 2016 45

PRACTICE #17 MEDICATION RECONCILIATION (pge numers referene NQF Sfe Prties for Better Helthre 2010 Updte report) 2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 17.1 In regrd to dverse drug events nd the medition reonilition proess, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: In regrd to the medition reonilition proess, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: ompleted review of the literture nd identified speifi est prties for proess redesign. (pp.225-228) ompleted review of the literture nd identified speifi evidene-sed est prties for proess redesign. (pp.225-228) onduted hospitl-wide evlution of the frequeny nd severity of dverse drug events ssoited with medition reonilition in our ptient popultion. sumitted report to the Bord (governne) with reommendtions for mesurle improvement trgets. (p.224) 17.2 In regrd to dverse drug events nd the medition reonilition proess, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: In regrd to the medition reonilition proess, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: 46

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording held senior dministrtive ledership diretly ountle for performne in this ptient sfety re through performne reviews or ompenstion. held the ptient sfety offier diretly ountle for improvements in performne through performne reviews or ompenstion. reported to the Bord (governne) the results of the mesurle improvement trgets. (p.224) 17.3 In regrd to dverse drug events nd the medition reonilition proess, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: In regrd to the medition reonilition proess, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: onduted stff edution/knowledge trnsfer nd skill development progrms, with ttendne doumented. (p.221) onduted n edution progrm for ll newly hired liniins on the importne of medition reonilition, with ttendne doumented. (p.219) lloted ompensted regiver stff time nd dedited line item udget resoures for est prties development for the orgniztion s medition reonilition system. (p.222) lloted proteted time for diret re stff nd mngers nd dedited udget resoures for est prties development for the orgniztion s medition reonilition system. (p.222) 47

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 17.4 In regrd to dverse drug events nd the medition reonilition proess, our orgniztion hs done the following within the lst 12 months or hs hd the following in ple during the lst 12 months nd updtes re mde regulrly: In regrd to the medition reonilition proess, our orgniztion hs done the following within the lst 12 months or hs hd the following in ple during the lst 12 months nd updtes re mde regulrly: developed nd implemented expliit poliies nd proedures ross the entire orgniztion regrding medition reonilition. implemented forml performne improvement progrm ddressing the impt of this speifi Sfe Prtie OR monitored previously implemented hospitl-wide performne improvement progrm tht mesures, nd demonstrtes full hievement of, the impt of this speifi Sfe Prtie. implemented stndrdized proesses to otin nd doument omplete list of eh ptient s urrent meditions t the eginning of eh episode of re. (p.219) d implemented stndrdized proesses to ensure tht omplete list of the ptient s meditions is ommunited to the next provider of servie, inluding the doumenttion of ommunition etween providers. (p.220) d 48

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording e implemented stndrdized proesses to provide the ptient, nd fmily/regiver s needed, urrent list nd explntion of the ptient s reoniled meditions upon the ptient leving the orgniztion s re. (p.220) e f hve reoniled meditions for ptients whose re setting, or level of re hs hnged, or hs hd hnge in helth sttus. (p.220) f 49

PRACTICE #19 HAND HYGIENE (pge numers referene NQF Sfe Prties for Better Helthre 2010 Updte report) 2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 19.1 In regrd to preventing hospitl-quired infetions relted to indequte hnd hygiene, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: onduted hospitl-wide evlution of the frequeny nd severity of hospitl-quired infetions in our ptient popultion nd the potentil impt of performne improvement prties relted to improvements in hnd hygiene. (p.250) onduted hospitl-wide evlution of the potentil impt of improvements in hnd hygiene on the frequeny nd severity of hospitlquired infetions in our ptient popultion. (p.250) sumitted report to the Bord (governne) with reommendtions for mesurle improvement trgets. 19.2 In regrd to preventing hospitl-quired infetions relted to indequte hnd hygiene, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: held linil ledership diretly ountle for this ptient sfety re through performne reviews or ompenstion. held senior dministrtive ledership diretly ountle for performne in this ptient sfety re through performne reviews or ompenstion. 50

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording held the ptient sfety offier diretly ountle for improvements in performne through performne reviews or ompenstion. d reported to the Bord (governne) the results of the mesurle improvement trgets. d 19.3 In regrd to preventing hospitl-quired infetions relted to indequte hnd hygiene, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: onduted stff edution/knowledge trnsfer nd skill development progrms, with ttendne doumented. (p.251) doumented expenditures on stff edution relted to this Sfe Prtie in the previous yer. 19.4 In regrd to preventing hospitl-quired infetions relted to indequte hnd hygiene, our orgniztion hs done the following within the lst 12 months or hs hd the following in ple during the lst 12 months nd updtes re mde regulrly: 51

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording developed nd implemented expliit poliies nd proedures ross the entire orgniztion to prevent hospitl-quired infetions due to indequte hnd hygiene inluding CDC guidelines with tegory IA, IB, or IC evidene. (p.250) implemented forml performne improvement progrm ddressing hospitl-quired infetions foused on hnd hygiene ompline, with regulr performne mesurement nd trking improvement (pp.250-251) OR monitored previously implemented hospitl-wide performne improvement progrm tht mesures, nd demonstrtes full hievement of, the impt of this speifi Sfe Prtie. (pp.250-251) 52

PRACTICE #23 HEALTHCARE-ASSOCIATED COMPLICATIONS IN VENTILATED PATIENTS (pge numers referene NQF Sfe Prties for Better Helthre 2010 Updte report) Does your fility re for ptients on ventiltors? Yes No If Yes, ontinue with the reminder of this Sfe Prtie. Otherwise, skip it; the Prtie does not pply. IMPORTANT NOTE: For purposes of this Sfe Prtie, ventiltor-ssoited omplitions inlude; ventiltor ssoited pneumoni, venous thromoemolism, pepti uler disese, dentl omplitions, nd pressure ulers. 2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording 23.1 In regrd to omplitions ssoited with ventiltor use, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: onduted n evlution of the frequeny nd severity of ventiltorssoited omplitions, speifilly ventiltor ssoited pneumoni, venous thromoemolism, pepti uler disese, dentl omplitions, nd pressure ulers in our ptient popultion nd ommunited findings to senior dministrtive nd linil ledership. (p.290) 53

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording sumitted report to the Bord (governne) with reommendtions for mesurle improvement trgets. 23.2 In regrd to omplitions ssoited with ventiltor use, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: held senior dministrtive ledership nd linil ledership diretly ountle for improvements in performne through performne reviews or ompenstion. held the ptient sfety offier diretly ountle for improvements in performne through performne reviews or ompenstion. reported to the Bord (governne) the results of the mesurle improvement trgets. 23.3 In regrd to omplitions ssoited with ventiltor use, our orgniztion hs done the following or hs hd the following in ple within the lst 12 months: 54

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording onduted stff edution/ knowledge trnsfer nd skill development progrms on est prties nd strtegies to redue omplitions with ttendne doumented. The orgniztion: The orgniztion: doumented or n doument expenses inurred during the pst yer tied to this Sfe Prtie. (p.293) doumented expenses inurred during the pst yer tied to qulity improvement efforts round this Sfe Prtie. (p.293) lloted ompensted regiver stff time nd dedited line item udget resoures for est prties development for the orgniztion s prevention of ventiltor ssoited omplitions. lloted ompensted regiver stff time for est prties development for the orgniztion s prevention of ventiltor ssoited omplitions. 23.4 In regrd to omplitions ssoited with ventiltor use, our orgniztion hs done the following within the lst 12 months or hs hd the following in ple during the lst 12 months nd updtes re mde regulrly: doumented evidene tht ll ventilted ptients re inluded in n pproprite dult or peditri speifi undle or prevention pln tht is lerly doumented in the medil reord. (p.293) 55

2015 Lepfrog Hospitl Survey Sfe Prtie Wording 2016 Lepfrog Hospitl Survey Sfe Prtie Wording implemented expliit orgniztionl poliies for the disinfetion, steriliztion, nd mintenne of respirtory equipment tht re ligned with evidened sed guidelines. (p.290) doumented evidene tht ll ventilted ptients nd/or their fmilies hve een eduted on prevention mesures involved in the re of the ventilted ptient. (p.292) d implemented forml performne improvement progrm with regulr performne mesurement nd trking improvement ddressing ventiltor ssoited omplition prevention nd ompline with prevention strtegies (p.293) d OR monitored previously implemented hospitl-wide performne improvement progrm tht mesures, nd demonstrtes full hievement of the impt of this speifi Sfe Prtie. (p.293) 56