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Response to 'Association Between Hospital-Reported Leapfrog Safe Practices Scores and Inpatient Mortality,' Journal of the American Medical Association (JAMA); April 1, 2009

Statement of Leah Binder, CEO

The Leapfrog Group

WASHINGTON, March 30 /PRNewswire-USNewswire/ --Today's JAMA study provides useful insight into the study of patient safety and inpatient mortality and will be used by The Leapfrog Group as we continually refine and improve the measures used in the Leapfrog Hospital Survey. Where possible, the measures included in the Leapfrog Hospital Survey are used and endorsed by quality advocacy organizations such as The Joint Commission, National Quality Forum (NQF) and Centers for Medicare and Medicaid Services (CMS).

The study addresses only one of many elements of the Leapfrog Hospital Survey -- the Safe Practices Score, which is a bundle of 13 NQF-endorsed safe practices. The Survey contains other elements including: measures of efficiency, common acute conditions, hospital acquired conditions, and most importantly, Leapfrog's three original safe practices ("leaps") which, as the researchers point out, have well-established correlations with risk-adjusted mortality and other positive outcomes.

The fact that this study could be done at all attests to our commitment to 100% transparency of healthcare information and data. Unfortunately, the comparison data set used by the researchers - the Nationwide Inpatient Sample - limits the conclusions that can be generalized from this study, as acknowledged by the study's authors.

The comparison data set used by the researchers confined them to using data from only 24 states, for a total of 155 hospitals, or 14% of the Leapfrog-reporting hospitals. Leapfrog's annual survey includes over 1,282 hospitals from all 50 states. The Leapfrog Group's three original leaps - implementation of computerized physician order entry systems, intensivist staffing in ICUs, and evidence-based hospital referral (for high risk procedures) - have been studied extensively and linked to improved hospital outcomes, including reduced mortality.

Most recently, Dr. Ashish Jha from Harvard Medical School and colleagues published a paper supporting this relationship in the Journal of the Joint Commission. A description of that publication is available at:

The process and structure measures in the Safe Practices Score are perfectly sensible. The idea that creating a safety culture, ensuring an adequate nursing workforce, preventing central venous line infections, and requiring hand washing, among other safety practices, would lead to a safer environment seems obvious.

But clearly we cannot assume that structural and process improvements automatically lead to the outcomes we desire. The JAMA study challenges health services researchers and measure developers to devise more direct measures of outcomes.

The Leapfrog Group will consider this study carefully and with the support of health care researchers, consider several questions about the hospital survey:

  • Should we give hospitals more credit for those items in the safe practices that require the most action?
  • Should we move away from a "training wheels" approach? Instead of providing hospitals credit for each individual step taken to achieve full implementation of a given practice, should we simply require a CEO's sign-off indicating the safe practice is being routinely followed?
  • Should we seek to raise the bar on the Safe Practices standard? Perhaps only a handful of the hospitals in the top quartile of our survey are doing enough about the safe practices to see demonstrable results.
  • Should we eliminate the safe practices entirely from the survey? It is difficult to believe that well established safety practices are not helpful to patients in profound ways, but with further research we will be able to objectively assess.

About The Leapfrog Group

The Leapfrog Group ( On behalf of the millions of Americans for whom many of the nation's largest corporations and public agencies buy health benefits, The Leapfrog Group aims to use its members' collective leverage to initiate breakthrough improvements in the safety, quality, and affordability of health care for Americans. The Leapfrog Group was founded in November 2000 by the Business Roundtable and is supported by its members, The Commonwealth Fund, the Agency for Healthcare Research and Quality and other sources.

SOURCE The Leapfrog Group
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