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The Answer Guide and Frequently Asked Questions (FAQs) for the NQF Safe Practices section of The Leapfrog Group’s Hospital Quality and Safety Survey

Important Notice:

Please review the FAQs below before answering the question for each Safe Practice. The NQF Safe Practices section of The Leapfrog Group Hospital Quality and Safety Survey are applicable for all hospitals(including rural and pediatric) unless noted in the FAQs below.

General FAQs for the Safe Practices:

1)Can the line item budget requirement be met if the budget includes categories which address the Safe Practice, but do not specifically name the Safe Practice?

Yes, if it can be verified that any of the additional specifications or example implementations can be

identified in a line item manner within a department budget that rolls up into the hospital budget; or if during the course of a current budget year, a department or hospital has a clear paper trail of any outlay of expenses specific to the safe practices the intent of this question will be met.

2)In the Awareness section of many of the questions the term “direct accountability” is used. What does this mean in the context of answering the questions?

Direct accountability refers to a senior or department level manager who has oversight responsibility for those areas of the hospital that implementation of any particular Safe Practice may impact. This person would be directly accountable through performance reviews or compensation incentives.

3)How does the assignment of individual accountability, ongoing monitoring, and management of the Safe Practice better meet these requirements?

The intent of this requirement is that an individual has accountability to assure the safe practice is fully implemented and maintained on an ongoing basis. Broad safety statements or monitoring “by committee” does not adequately meet this requirement.

4)The phrases “personal performance reviews” and “personal compensation incentives” are used throughout the survey within many Accountable responses. Do such reviews and incentives need to have specific language about a safe practice, or can a set of patient safety goals be attached?

A performance review or incentive plan should include specific language about a safe practice. A list of safe practices and related goals may be incorporated into the performance review and/or incentive plan.

5)If education policies and procedures for a Safe Practice are already in place and compliance is monitored, are annual staff education and skill development programs still required?

Even if policies and procedures for a safe practice are already in place and compliance can be monitored, annual education sessions or skills fairs are required to address frequent high staff turnover, use of agency/traveler staff, and updated changes in policies and practices.

2)6)Education is a frequent requirement for credit throughout the survey. How should employee education be measured?

To qualify for credit, educational meetings should clearly address the subject matter pertinent to adverse events and performance improvement targeted by the Safe Practice being surveyed. Hospitals should track meeting or presentation dates,frequency of employee training sessions provided, attendance recordsand the percent of the total employee populationwho received the information.

If education policies and procedures for a Safe Practice are already in place and compliance is monitored, are annual staff education and skill development programs still required?

7)If a staff educator’s role and function include education specific to the Safe Practices, does this meet the line item budget requirement, or does the budget need to allocate a specific amount of time to the Safe Practices?

If the staff educator’s job description identifies the specific safe practices they address in their educational role, the intent of this item is met. Any documentation of training or education time spent on a safe practice or expenditures on educational supplies or meeting preparation materials that address any of the safe practices will meet the intent of the line item budget requirements. Specific time allocations per safe practice are not required as long as there is documentation of staff participation through meeting minutes and attendance records.

8)Why is it necessary to continue to review a safe practice once it has been implemented?

All too often in the hectic pace of providing patient care in a hospital; with frequent staff turnover and lots of part-time employees; it is difficult to get a change in practice well established. Annual review with monitoring and tracking of the safe practices will assure they are embedded in the operations of the hospital and not lost in the shuffle of new staff coming in or part-time employees coming and going.

9)Why do some commitment responses have a higher level of expectation than the action response for the same question within a Safe Practice?

Commitment responses are designed to “set the bar higher,” and generally require expansion of patient safety practices and activities across the hospital. Hospitals which have not yet met the action response requirements may need to accelerate efforts to achieve a higher level of performance.

10)Why do some questions include a commitment response option, and some questions do not?

Commitment responses are designed to require a higher level of performance (e.g., expansion of specified activities across the hospital). For some safe practices, a hospital-wide focus would not be required, and therefore some answers do not include a commitment response option.

11)The term “senior executives” is used through out the survey. What employee categories would qualify as senior executives?

For the purposes of the survey, “senior executives” refers to managers who are responsible for hospital-wide departments or services.

3)12)How is the term “regular” used in the survey?

For the purposes of the survey, “regular” shall mean at least monthly, if typical meeting or reporting activities are undertaken. If aggregated data is being gathered and analyzed, then such reporting may be quarterly for the data component.

4)13)The term “enterprise-wide” is used throughout the survey. Does this mean throughout the hospital, or throughout a health system?

Since individual hospitals are required to complete the survey, “enterprise-wide” refers to departments within a hospital. For hospitals which are part of a larger health system, a desired patient safety goal would be to roll out best practices in a coordinated program across the entire system..

Can the line item budget requirement be met if the budget includes categories which address the Safe Practice, but do not specifically name the Safe Practice?

Yes,

When determining whether a hospital has satisfied the requirement of having a “line item budget allocation” to a Safe Practice, how many items cited in the NQF Safe Practices report Additional Specifications or Example Implementation Approaches need to have explicit line item budget allocations?

If it can be verified that any of the additional specifications or example implementations can be identified in a line item manner in the budget, then the intent of the question will be met.

If a staff educator’s role and function include education specific to the Safe Practices, does this meet the line item budget requirement, or does the budget need to allocate a specific amount of time to the Safe Practices?

If the staff educator’s job description identifies the specific safe practices they address in their educational role, the intent of this item is met. Specific time allocations per safe practice are not required as long as there is documentation of staff participation through meeting minutes and attendance records.

In the Awareness section of many of the questions the term “direct accountability” is used. What does this mean in the context of answering the questions?

Direct accountability refers to a senior or department level manager who has oversight responsibility for the area of the hospital that implementation of any particular Safe Practice may impact. This person would be directly accountable through performance reviews or compensation incentives.

5)14)The phrase “frequency and severity of …” is used throughout the survey within many Aware responses. What is the intent and how can a hospital satisfy this requirement?

In order for a hospital to be fully aware of the extent that any patient safety issue exists within the organization, a hospital needs to review all adverse events to determine how often they occur and establish an impact severity scale to the patient (e.g., the NCC MERP Index).

How does the assignment of individual accountability, ongoing monitoring, and management of the Safe Practice better meet these requirements?

The phrases “personal performance reviews” and “personal compensation incentives” are used throughout the survey within many Accountable responses. Do such reviews and incentives need to have specific language about a safe practice, or can a set of patient safety goals be attached?

6)15)What constitutes direct and regular reporting to trustees or boards of directors by a Patient Safety Officer?

A senior executive (who may or may not have the title “Patient Safety Officer”) satisfies this reporting requirement if he or she has responsibility for multiple and integrated areas of patient safety. Multiple executives, who may be responsible for one area of safety each, however do not assess the overall integrated safety issues, would not qualify.

Individual department safety reports may be submitted to a Patient Safety Officer or senior executive responsible for safety, who provides a comprehensive report to the Board.
Direct means personal reportingto a safety or quality sub-committee of a board of trustees/directors or direct reportingto the board.
Regular means monthly regarding status reporting. If aggregated data is being gathered and analyzed, then such reporting may be quarterly for the data component.

16)Can a designated full-time employee spending the majority of their time coordinating and integrating the activities for patient safety qualify as a Patient Safety Officer?

Yes, as noted above, the title of Patient Safety Officer is not a requirement.

17)Numerous survey questions provide opportunities to generate credit for having undertaken Performance Improvement Programs or for committing to undertake them. What are the minimum requirements to qualify as such a program?

Performance improvement programs should include all of the following five elements: Education regarding the pertinent adverse event frequency, severity, and/or impact of best practices, skill building in use of performance improvement tools, measurement of process measures or outcomes measures, process improvement, interventions, and reporting of performance outcomes.

Why do some commitment responses have a higher level of expectation than the action response for the same question within a Safe Practice?

Why do some questions include a commitment response option, and some questions do not?

18)How would a hospital earn maximum points for all of the Action sections dealing with Performance Improvement projects/programs?

A hospital thathas undertaken performance improvement projects on individual units and throughout the entire hospital facility would receive full credit for both. Performance Improvement Programs must have the five elements addressed in FAQ #17above.

Safe Practice # 1

Create a Healthcare Culture of Safety

GeneralHospital

19)Ref Survey Questions 1.1, 1.13, 1.14, 1.21,1.22: What subject matter qualifies for credit foreducational programs in the Awareness section of the culture questions?

To qualify for credit, educational meetings should clearly address the “Additional Specifications” and “Example Implementation Approaches” sections of the NQF Safe Practices report that relates to creating a culture of safety. Educational topics that qualify also include reliability science, systems theory and thinking, simulation, Complex Adaptive System theory, human factors science, and use of Failure Mode and Effects Analysis.

20)Ref Survey Question 1.1:If a hospital is involved in the IHI 100,000 Lives Campaign regarding Deployment of Rapid Response Teams, does this help address the Awareness expectations of this survey question?

Yes, If a hospital is collecting data on the frequency and severity of incidents of “Failure to Rescue” and is submitting this data as part of the intervention of Rapid Response Teams, this will provide credit towards the Awareness answers for this survey question.

21)Ref Survey Questions 1.1, 1.13, 1.14, 1.21, 1.22: How should employee education be measured?Hospitals should track meeting or presentation dates, frequency of employee training sessions provided, attendance records,and the percent of the total employee population attending the educational programs.

22)Ref Survey Question 1.2: What qualifies as a cultural survey? Does an employee satisfaction survey qualify?
A number of surveys are readily available that specifically address culture, safety climate,and teamwork. A general employee satisfaction survey that only measures employee satisfaction does not qualify.

23)Ref Survey Question 1.2: How can a valid and measurable self-assessment process be established?
The intent of this Safe Practice addresses a similar issue being addressed in the JCAHO standard PI 1.1.0 (which addresses staff and customer satisfaction). A Culture survey must be undertaken at minimum once yearly across all the organization. Progress must be tracked and specific strategies for remediation and performance improvement implemented.

24)Ref Survey Questions 1.2, 1.23, 1.25: Can data collection from use of Trigger Tools be used for this Safe Practice?

Yes. Supporting source data to answer this question may includethe numberof charts reviewed using a Trigger Tool or incident reporting (see example implementation approaches); performed manually or on an automated basis.

25)Ref Survey Question 1.23: If a hospital joins the IHI 100,000 Lives Campaign and has implemented a Performance Improvement project to deploy Rapid Response Teams, does this help address the Action expectations of this survey question?

Yes. If a hospital has developed a Performance Improvement project to implement Rapid Response Teams this will provide credit towards the Action answers for this survey.

26)Ref Survey Question 1.3, 1.4, 1.9: What employee categories are meant by the term senior executives?
For the purposes of the survey, “senior executives” refers to managers who are responsible for hospital-wide departments or services.

27)Ref Survey Questions1.3,1.4, 1.11: What does the term “regular” mean in terms of senior executives in reporting or measurement of performance?
For the purposes of the survey, “regular” shall mean at least monthly, if typical meeting or reporting activities are undertaken. If aggregated data is being gathered and analyzed, then such reporting may be quarterly for the data component.

28)Ref Survey Question 1.3: What is meant by Executive Walk Arounds and how often should it take place?
The Executive Walk Arounds provide visibility and access to senior management by frontline clinical staff. Management has the opportunity to address issues and concerns in various departments while they are on site. Monthly meetings with staff in a centralized location do not meet the intent of this Safe Practice.

29)Ref Survey Question 1.3: What is the value of Executive Walk Rounds?

Executive Walk Arounds provide visibility and direct access to senior management by frontline clinical staff, and as such createan opportunity to address safety issues and concerns in various departments while on site. The process also provides an opportunity for feedback on implementation of improvement strategies and tactics.

30)Ref Survey Question 1.3: How can progress on the implementation of Executive Walk Rounds be measured?

The number of walk arounds performed per unit or clinical area may be measured for designated time periods. Some progressive hospitals have tied incentives to regular executive walk arounds and to reliable exchange of information on clinical unit performance.
Some hospitals have established a feedback loop between senior executives and frontline staff to measure the implementation of performance improvement ideas that were generated by Executive Walk Rounds.

31)Ref Survey Questions 1.6, 1.20: What types of events should be included in “incidents,” “errors,” and “reported events?” Does this include only major incidents and near misses, or all events reported?

A hospital needs to review all reported adverse events and near misses.

32)Ref Survey Question 1.7: Safety Culture has a very heavily weightedscore contribution. How will hospitals that have made real progress in culture be recognized over hospitals that have not made as much progress, however make major commitments to increase their scores in the survey?
Hospitals are ranked in quartiles based on their raw score out ofa possible 1,000 points. Of this, Safety Culture is 263 points. To rank in the topquartilehospitals have to meet the twofollowing requirements: