Taking Big Steps: Strategies to Improve Leapfrog Safety Scores
Interest from the public and policymakers in transparency in health care put patient safety metrics in the limelight. The Leapfrog Group introduced hospital safety grades in 2012, as an effort to provide health care consumers information about their local hospitals. The safety grade consists of assigning a letter grade of A, B, C, D, or F, signifying a level of safety within the organization.
Safety grades are updated twice a year and include 28 different national patient safety measures. The safety grade contains data from the Leapfrog Hospital Survey and data from other publicly reported sources, including the Centers for Medicare and Medicaid Services (CMS). The Leapfrog safety score produces a safety grade for more than 2,700 acute care hospitals twice a year. These measurements fall into two different domains: 1) process and structural measures, and 2) outcome measures; each measure accounts for 50% of the overall score. Process measures represent how often a hospital gives a patient recommended treatment for a given medical condition or procedure. Structural measures represent how patients receive care; for example, whether doctors order medications through a computer.
Patient outcomes are supplied through publicly reported data, or the hospital provides this information during the survey process. Leapfrog may use a supplemental data source, when a hospital’s information is not readily available. A hospital must have enough data for a letter grade to be issued; consequently, hospitals missing more than seven process measures or five outcome measures are not graded. Although hospitals are encouraged to report additional safety data voluntarily, they are not required to do so to receive a safety grade. At this time, Leapfrog does not assign letter grades to military or Veterans Affairs hospitals, critical access hospitals, specialty hospitals, children’s hospitals and outpatient surgery centers.
Strategies to make the grade
The following strategies can be used to improve a hospital’s overall safety grade.
1) Understand how the metrics are used to provide a score or hospital safety grade.
The 13 process/structural measures and 15 outcome measures have an associated evidence score, opportunity score, impact score, and measure weight that contributes to the overall letter grade. It is essential to understand how each metric is scored and weighted when analyzing a hospital grade. Leapfrog hospital safety grade information and scoring methodology can be found on the Leapfrog website.
Hospital strategies to improve any metric should be based on 1) the ability to change behaviors related to the metric and 2) the overall measure weight. By focusing on measures that have a higher contributing factor to a hospital safety grade, a bigger impact will be observed. A hospital I worked with several years ago moved one full safety grade by working on all of the structural measures. The administrative executive team went through each structural measure and identified areas of weakness. Each team member was assigned measures and reported back weekly during executive team meetings. By making the Leapfrog safety grade part of the executive team discussion, team members were able to implement new processes, and hold managers and staff accountable. In addition, these measures and process changes were all reported to the hospital board. The hospital board became an integral part of this organization’s journey to improve patient safety. Quality data, process and structural measures also were reported to the medical executive committee (MEC) quarterly. The MEC became involved in understanding patient safety and quality issues and was able to assist in changing physician behaviors as needed. Physicians also were able to see quickly how their actions with antibiotic stewardship, computerized provider order entry and hand hygiene affected this safety grade. Quality and patient safety data became significant in everyone’s eyes and was foremost on the agenda of hospital operations.
2) Understand publicly reported data and reporting period.
Publicly reported data that is used in the safety grade comprises a rolling 12-month reporting period. This data may be delayed based on when it is made available. For example, hospital patient experience data consists of a reporting period of Oct. 1, 2017, to Sept. 30, 2018, for the Spring 2020 Safety Grade. Other CMS reported data such as falls, air embolism, retained foreign object has a reporting period of July 1, 2016, to June 30, 2018. It takes time to see the results of public reported data as old scores fall from the date range when improvements are made.
Hospital-acquired infection measures are less delayed depending on the data source. When the hospital participates, the reporting period is Jan. 1, 2018 to Dec. 31, 2018, if Leapfrog must rely on CMS reporting as a secondary source, the reporting period is Oct. 1, 2017 to Sept. 1, 2018. Again, because of the delayed reporting dates, providing Leapfrog with primary data becomes an advantage if improvement initiatives are underway.
Understanding and utilizing the data that comprises the hospital patient safety score is an essential factor when strategizing how to improve the hospital’s overall safety grade. The quality director can provide insights to understand data. Utilizing the hospital’s infection prevention specialists is another example of how one hospital improved its hospital- acquired infections measure. Through handwashing audits, it was observed that some nurses were not adhering to the artificial nail policy, as well as not properly washing hands. As the team evaluated the data, it was determined that nurses were not the only staff needing improvement in handwashing/hand sanitizing methods. The hospital chose to look to others for examples on how to improve hand hygiene. Graupp and Purrier (2012) provided such an example, which produced dramatic results at one West Coast medical center.
A team of eight leaders was quickly formed to carefully implement this model outlined by Graupp and Purrier (2012). Every staff person with patient contact would be trained in appropriate hand hygiene practice. This was not an easy task and took considerable time, effort and energy from everyone in within the hospital. Hand hygiene became a focus in every manager meeting, executive team meeting, MEC meeting, and hospital board meeting. The hospital saw results of decreased hospital-acquired infections within a few months by using this simple method of educating, training and monitoring hand hygiene. Those results have been maintained for more than 10 years.
3) Strategize on where your organization can receive the most significant gains.
It may be tempting to tackle every data point at once while trying to improve a safety score, but it is wise to allocate resources towards maximizing gains. As referenced earlier, a hospital I worked with started on structural measures first, next tackled hospital-acquired infections and then focused on ICU physician staffing metrics. The hospital had to employ or contract with enough ICU-trained physicians, ensure they were the primary rounding physician on all ICU patients and meet the physician inhouse/readily available requirement. Austin and Derk (2019) found that fully implementing the Leapfrog ICU physician staffing measure reduced ICU mortality by 30%. Leapfrog uses evidence-based research to establish best patient safety practices. Keep in mind that resources are limited in every setting, and by prioritizing where resources are added, hospital leaders can focus on incremental improvements providing overall quality and patient safety.
Creating a safety culture
A hospital’s safety grade will not improve overnight. The outcome quality data, processes and systems determining a hospital’s score have been years in the making. For example, one hospital took four years to move from a “C” to an “A” grade. Hospital leaders worked on each selected metric in sequence, careful to hold on to gains established from previous work until they were able to reach an “A” grade. Everyone in the organization became quality and patient safety champions. Each change had to become the new way of providing care.
As nurse leaders we are at the helm of patient safety and quality care that is provided in our organizations. The real work is ensuring patients receive the best care possible. Achieving a high Leapfrog hospital safety grade is the result of that work. In my experience, hospital leaders have found these efforts to be worthwhile to the patients and families that entrust them with their care. The 28 measures used to encompass this grade can be challenging to improve, but through efforts of an entire team, these improvements can be made and sustained.
Note: This article was based on hospital experiences from 2014 to 2018. Since that time, Leapfrog has changed the way the safety grade is measured and the metrics used to ensure patient outcomes related to safety.
References
Austin, M., & Derk, J. (2019). Lives lost, lives saved: An updated comparative analysis of avoidable deaths at hospitals graded by The Leapfrog Group. https://www.hospitalsafetygrade.org/media/file/Lives-Saved-White-Paper-FINAL.pdf
Graupp, P., & Purrier, M. (2012). Getting to standard work in health care: Using TWI to create a foundation for quality care. CRC Press.
Leapfrog Group. (2020). Leapfrog hospital safety grade. https://hsg-stage.workcenter01.atlasworks.com/your-hospitals-safety-grade/about-the-grade
About the Author
Marie Prothero, PhD, RN, FACHE, is assistant professor at Brigham Young University, Provo, Utah. She previously served as nurse executive at Shriners Hospital for Children, Salt Lake City.