Download SECTION A: GENERAL PEDIATRICS PLEASE NOTE: Answers to

SECTION A: GENERAL PEDIATRICS
PLEASE NOTE: Answers to the questions in this section will be used to assess hospital capabilities and
performance in one or more specialty areas. The section is called general pediatrics to avoid repeating the
questions in individual specialty areas.
When responding to questions in this section, your hospital must consult with the chief of service
(or equivalent) of your Pediatric program to ensure that answers are accurate and consistent with
both the care delivered and the intent of the survey.
As data are reviewed, U.S. News may have questions about responses to individual questions or
about an entire submission. To ensure communication with the appropriate clinical leader, please
provide the following information about the chief of service (or equivalent) for your Pediatric
program.
Full name:
Title:
Email:
Preferred phone:
REQUIRED: IF NAME, TITLE, EMAIL, OR PHONE=BLANK, DISPLAY: “A response is
required for [Name/Title/Email/Phone] prior to submitting the survey. Click “OK”
to continue with the survey and answer this question later. Click “Cancel” to
provide a response to this question now.”
A1.
What was the average daily pediatric (including newborns1 and neonates) inpatient census2
for the last 2 calendar years?
________ 2015 average daily inpatient census
________ 2016 average daily inpatient census
A1.2
What was the total number of beds set up and staffed for use3 at the end of the past year?
________ Number of setup and staffed beds
1
For hospitals with labor and delivery services, only include newborns that were admitted to the pediatric program for care in the
NICU, PICU, or one of the pediatric specialty units.
2 Inpatient days divided by the number of days that the hospital was open (e.g. 365).
3
Please report only operating beds, not constructed bed capacity that is not currently in use. Include all bed facilities that are set
up and staffed for use by pediatric inpatient care. Exclude beds that have been newly constructed but are not yet in use and all
temporary beds such as post anesthesia, postoperative recovery room beds, psychiatric holding beds, and beds that are used only
as holding facilities for patient prior to a transfer to another hospital.
Last updated: 2/17/2017
A2.
Indicate the number of full-time equivalent (FTE)4 on-staff RNs in your pediatric program
(including the NICU and perioperative nursing staff) who are involved in direct inpatient
pediatric care. (Exclude LVN, LPN, UAP NPs, PAs, contract nurses, ED staff, urgent care staff,
and outpatient-only nursing staff. Include all clinical RNs who would normally be replaced if
they called in ill.)
________ Number of FTEs
A3.
As of January 1, 2017, was your hospital designated as a Nurse Magnet Facility by the
American Nurses Credentialing Center?
 Yes
 No
A4.
Does your hospital have at least one of the following specialists available on-site (during
normal business hours) and on-call5 (afterhours and weekends) for consultation in your
pediatric program 24 hours a day, 7 days a week?
Yes
No
a. Pediatric anesthesiologists (board certified/board eligible in Pediatric
Anesthesiology by the American Board of Anesthesiologists)
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b.
c.
d.
e.
f.
g.
WARNING:
Pediatric critical care specialists (board certified/board eligible5 by the
American Board of Pediatrics with subspecialty certification in
pediatric critical care medicine)
Pediatric radiologists specializing in diagnostic radiology (board
certified/board eligible by the American Board of Radiology) with a
fellowship or other training in pediatric diagnostic radiology (with at
least 75% of all radiologists having a certificate of added qualification
in pediatric radiology by the American Board of Radiology)
Radiologists specializing in pediatric interventional radiology (board
certified/board eligible by the American Board of Radiology in
diagnostic radiology with a certificate of added qualification in
pediatric radiology or interventional radiology by the American Board
of Radiology) and practicing more than 50% time in pediatric
interventional radiology
Pediatric rheumatologists6(board certified/board eligible5 by the
American Board of Pediatrics with subspecialty certification in
pediatric rheumatology)
Pediatric infectious disease specialists (board certified/board eligible5
by the American Board of Pediatrics with subspecialty certification in
pediatric infectious disease)
Pediatric physiatrist (board certified/board eligible by the by the
American Board of Physical Medicine and Rehabilitation with
subspecialty certification in Pediatric Rehabilitation Medicine)
IF A4c OR A4d=Yes, GO TO A4.1; ELSE SKIP TO A5.
4
Calculate FTEs based on total paid hours for the period of review divided by 2080.
On-call staff must be available to attend patients on-site if required
6 May count if available 7 days a week, but not 24 hours a day.
5
Last updated: 2/17/2017
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A4.1
Please report the total FTE pediatric interventional radiologists in your pediatric
program and the number of pediatric interventional radiologists that spent ≥ 0.5
FTE practicing interventional radiology in the last calendar year? [If none, please
enter 0.]
_______ Pediatric interventional radiologist FTEs
_______ Number practicing pediatric interventional radiology ≥ 0.5 FTE
VALIDATE: IF A4.1b IS NOT A WHOLE NUMBER, DISPLAY: “A4.1b: Please enter a whole
number (no decimals).”
A5.
Does your hospital have at least one of the following pediatric surgeons (board
certified/eligible from the appropriate surgical board, with a fellowship training in pediatric
surgery) available to your pediatric program?
a.
b.
c.
d.
e.
f.
g.
h.
Pediatric otolaryngology surgeon
Pediatric cardiothoracic surgeon
Pediatric general surgeon
Pediatric neurosurgeon
Pediatric ophthalmology surgeon
Pediatric orthopaedic surgeon
Pediatric urology surgeon
Pediatric plastic surgeon
Last updated: 2/17/2017
Yes
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No
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A6.
Did your hospital sponsor (or host a rotation site for) at least 1 fellow in the past academic
year who is enrolled in an approved Accreditation Council for Graduate Medical Education
(ACGME) training program in the following subspecialties? [If hosting a rotation, please
list the sponsoring institution.]
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
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p.
q.
r.
s.
t.
u.
Child neurology7
Congenital cardiac surgery
Neonatal-perinatal medicine
Neurosurgery8 (with training in pediatrics)
Pediatric cardiology
Pediatric endocrinology
Pediatric gastroenterology
Pediatric hematology-oncology
Pediatric nephrology
Neuroradiology (with training in pediatrics)
Pediatric pulmonology
Pediatric urology
Pediatric surgery
Pediatric infectious diseases
Orthopaedic surgery of the spine (with training in
pediatrics)
Pediatric critical care medicine
Pediatric advanced transplant hepatology
Pediatric rheumatology
Physical medicine and rehabilitation (with training
in pediatrics)
Pediatric radiology
Interventional radiology (with training in pediatrics)
7
Yes
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No
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Sponsor
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For this item, please count the Child Neurology residents in your program.
While there currently is not an ACGME program for pediatric neurosurgery, there is for neurosurgery. If you have fellows in
ACGME program 160 (neurosurgery) who are completing their fellowship requirements at your site they should be included. In
addition, if you have fellows who are participating in an ACPNF (Accreditation Council for Pediatric Neurosurgery Fellowships)
approved program onsite, they may be counted as well.
8
Last updated: 2/17/2017
A7.
Does your hospital provide the following pediatric services either on-site or through a
formal contractual relationship with another facility?
Yes
No
a. Neonatal intensive care unit9 (NICU)
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b. Pediatric intensive care unit10 (PICU)
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c. Patient care rooms with protective environment11
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d. Genetic testing/counseling 12
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e. Palliative care program
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f.
Rehabilitation program and consultation service14
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A8.
Does your hospital provide the following pediatric services on-site which are available 24
hours a day, 7 days a week?
Yes
No
a. Rapid response team15
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b. Pediatric anesthesia program16
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c. Pediatric pain management program17
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d. Multidisciplinary pediatric acute pain/sedation service18
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9
A NICU provides mechanical ventilation, neonatal surgery, and special care for the sickest infants, including those with the
lowest birth weights (below 1,500 grams), who are born in the hospital or transferred from another institution. The NICU is
separate from the newborn nursery. A full-time neonatologist serves as director.
10 A PICU is staffed with specially trained personnel and has monitoring and specialized support equipment for treating pediatric
patients who, because of shock, trauma, or other life-threatening conditions, require intensified, comprehensive observation and
care.
11 The Protective Environment incorporates the following: air exchanges > 12 per hour; central or point-of-use high-efficiency
particulate (HEPA) filters, consistent positive air pressure differentials between the patient’s room and hallway and continuous
monitoring of pressure differentials.
12 A genetic testing/counseling service is equipped with the appropriate laboratory facilities and is directed by a physician
qualified to advise parents and prospective parents on potential problems in cases of genetic defects. A genetic test is the analysis
of human DNA, RNA, chromosomes, proteins, and certain metabolites in order to detect heritable disease-related genotypes,
mutations, phenotypes, or karyotypes for clinical purposes. Genetic tests can have diverse purposes, including the diagnosis of
genetic diseases in newborns, children, and adults; the identification of future health risks; the prediction of drug responses; and
the assessment of risks to future children.
13 A palliative care program is organized and staffed for children nearing the end of life or living with lifespan-limiting
conditions. The program’s purpose is to minimize pain and discomfort, provide emotional and spiritual support for children and
their families, assist with financial guidance and social services, and support decision making. Programs must include at least one
physician providing direct patient care; a nurse coordinator; and a social worker, certified child-life specialist, or pastoral
counselor. All program staff must have training in palliative care.
14
This program provides either a rehabilitation unit and/or a consultation service within the pediatric program for patients
requiring rehabilitation. The program must include a pediatric physiatrist (board certified/board eligible pediatric rehabilitation
physician) as the director.
15 A rapid response team, also known as a medical emergency team, is distinct from the hospital “code” team. The team of
appropriately trained individuals is available 24 hours a day and has three essential characteristics: (1) The team creates tools and
provides staff education for recognizing an acute deterioration in patient condition. (2) The team follows the SBAR method (for
situation, background, assessment, recommendation) to communicate such a change in condition effectively and efficiently (i.e.,
escalation policy). (3) The team responds to the change in condition with the goal of reducing/eliminating preventable “codes.”
16 This team provides anesthesia care for children before, during, and after surgery (or other medical procedures). The team
provides 24-hour coverage by board-certified anesthesiologists who specialize in pediatric anesthesia.
17 Administered by specially trained physicians and other clinicians, this is a recognized clinical service or program providing
specialized medical care, drugs, or therapies for the management of acute or chronic pain and other distressing symptoms among
children suffering from an acute illness of diverse causes.
18 This service provides monitored anesthesia care and sedation within the hospital (but not within an operating room or PICU),
as well as emergency airway management and acute and chronic pain management for neonates and pediatric patients on a 24hour basis. A qualified program must have at least an identified medical director (e.g., general pediatrician, pediatric
subspecialist, or anesthesiologist) with documented education in conscious sedation and an RN coordinator (or pain management
clinical nurse specialist).
Last updated: 2/17/2017
A9.
Is your ECMO program currently designated as a Center of Excellence by the
Extracorporeal Life Support Organization (ELSO)?
 Yes
 No
 Not applicable—we do not have an ECMO program
A10.
Does your hospital provide on-site access to the following technologies or services to
pediatric patients?
Yes
a. Positron emission tomography19/magnetic resonance imaging
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(PET/MRI) single-console combined scanning unit
b. Positron emission tomography/computed tomography (PET/CT)
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single-console combined scanning unit20
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c. Intraoperative magnetic resonance imaging (ioMRI)
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d. 3 Tesla magnetic resonance imaging (3T MRI)22
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e. Image-guided radiation therapy (IGRT)
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f. Intensity-modulated radiation therapy (IMRT)24
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g. Portable CT scanning unit25
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h. Ultrasound for suspected appendicitis in pediatric patients
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i. Fast shunt magnetic resonance imaging MRI for hydrocephalus26
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j. Dedicated interventional radiology (IR) team (techs and nurses) to
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support IR procedures
No
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A10.1 Which of the following does your pediatric program offer to ensure quality and patient
safety (e.g., reduce exposure to radiation)?
Yes
No
a. Designated medical director of radiology who oversees quality and
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safe practice in the pediatric program
b. Iterative reconstruction software in computed tomography (CT)
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scanners
c. An MRI safety program compliant with the American College of
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Radiology (ACR) guidelines
19
PET scanning is a computerized nuclear medicine imaging technology that uses radioactive (positron-emitting) isotopes
created in a cyclotron or generator to produce composite images of the brain and heart activity. The scans are sectional images
depicting metabolic activity or blood flow rather than anatomy.
20 PET/CT combines the capabilities of PET and CT scanning into a single integrated device, which provides metabolic
functional information for monitoring chemotherapy, radiotherapy, and surgical planning.
21
ioMRI uses a uniform magnetic field and radio frequencies to study tissue and structure of the body. It enables visualization of
biochemical cellular activity in vivo without the use of ionizing radiation, radioisotopes, or ultrasound.
22 3T MRI is a higher-powered version of MRI that offers improved morphological and functional studies of the brain compared
with the more common field strength of 1.5T.
23 IGRT is an automated system that produces high-resolution x-ray images to pinpoint tumor sites, adjust patient positioning,
and generally make treatment more effective and efficient.
24 IMRT is a three-dimensional radiation therapy that improves the targeting of treatment delivery in a way that is likely to
decrease damage to normal tissues and allows for varying intensities.
25
CT scanning unit that can be moved to where patient care is being provided rather than having a fixed unit in a
single location. The portable unit is particularly helpful in delivering care in the ICU, emergency department, and in
operating room environments.
26
Fast MRI shunt scans are exams performed in under 10 minutes as an alternative to CT scans to assess ventricular
size when shunt tube malfunction is suspected.
Last updated: 2/17/2017
A10.2 Does your pediatric program use computerized tomography (CT) protocols that adjust
milliampere-second (mAs) and peak kilovoltage (kVp) based on patient size and/or weight?
 Yes
 No
A10.3 Does your pediatric program currently maintain the following certifications?
a.
b.
c.
d.
e.
f.
Accreditation in computerized tomography (CT) imaging from the
American College of Radiology (ACR)
Accreditation in nuclear medicine from the American College of
Radiology (ACR)
Pediatric sonographer accreditation by the American Registry for
Diagnostic Medical Sonographers (ARDMS) or ultrasound
accreditation by the American Registry of Radiologic
Technologists (ARRT)
Program accreditation in ultrasound from the ACR or AIUM
Accreditation in MRI from the ACR
American Registry of Radiologic Technologists (ARRT)
certification for x-ray technologists
Yes
No
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A10.4 Does your pediatric program have regularly scheduled multidisciplinary case
conferences with pediatric radiologists to review the following test results?
Yes
a. Review all abnormal brain and pituitary MRIs with a pediatric
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neuroradiologist
b. Review abdominal and pelvic ultrasounds with a pediatric radiologist
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c. Review abnormal thyroid ultrasounds with a pediatric radiologist
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No
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A10.5 Do patients undergoing MRI, CT, or voiding cystourethrogram (VCUG) scans meet with or
are they provided access to a certified child life specialist to discuss the procedure and
alleviate patient stress?
 Yes
 No
A11.
Does your hospital provide at least one of the following technologies for pediatric patients,
either on-site or through an arrangement with another facility27: Linac or other linear
particle accelerator, Gamma knife, Cyberknife, or other shaped-beam stereotactic radiation
therapy?
 Yes
 No
To respond “yes” to this item, the arrangements for use of these tools with another facility should be based on a formal
contractual relationship.
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Last updated: 2/17/2017
A12.
Do pediatric patients and their families have direct access to the following providers via a
telephone number, paging system, or electronic means such as email rather than first
requiring a referral?
a.
b.
c.
Certified child-life specialists
Family support specialists28
Pediatric psychologists or psychiatrists
Yes
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No
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A12.1 Do pediatric patients and their families have direct access to in-person interpreters for
medical and surgical discussions when needed?
 Yes
 No
A13.
Do pediatric patients and their families have direct access to the following inpatient
services?
a.
b.
c.
d.
A14.
Family resource center29
Sleep areas for parents or siblings
School intervention program30
Ronald McDonald House or other residential facility for parents
convenient to the hospital
Yes
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No
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Do you have a parent advisory committee that meets at regular intervals?
 Yes – Go to A14.1
 No – Skip to A15
A14.1 If “yes” to A14, how frequently does your parent advisory committee meet during
the year?
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1 time
2 or 3 times
4 or 5 times
6 or 7 times
8 times or more
Not applicable
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Family support specialists help families meet practical needs (e.g., school coordination, transportation, lodging, etc.),
information needs (e.g., family resource center, access information, etc.), and in some cases making appropriate connections back
to their child's clinical treatment team. The primary goal of the family support specialist is to facilitate meeting the practical and
information needs of families of patients being seen for care at your hospital.
29 Family resource centers should provide patients and families access to a wide variety of information about child and maternal
health and well-being. To receive credit, a hospital must have paid staff that are designated to run and support the center.
30 A school intervention program works with the patient, the family, and the school to sensitize schools to the needs of the
patient. The school intervention program must include a) a provision for providing education services during prolonged
hospitalizations, and b) transition services for return to school after change in medical, functional, or cognitive status.
Last updated: 2/17/2017
A15.
Please answer the following questions about parent/family member involvement in your
pediatric program.
Yes
No
a. Does at least one parent or family member of a current or former patient
serve as an active voting member on the strategic or facility planning
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committee for your pediatric program?
b. Does at least one parent or family member of a current or former patient
serve as an active voting member on one or more standing committees
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(e.g., quality, patient safety, and ethics)?
c. Can parents or family members participate in clinical care decision
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making processes such as care conferences in your pediatric program?
d. Can parents or family members participate in family-centered rounds in all
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services of your pediatric program?
A15.1 If “yes” to any part of A15, please describe what roles parents or family members
serve in on committees and clinical decision making process, and what kind of an
impact this has had on your pediatric program in the last year:
A16.
Does your pediatric program publicly report performance data on one or more quality
metrics by displaying the data on the hospital's or program's website?
 Yes
 No
A16.1 If “yes” to A16, please describe the data reported, the frequency of updates, and the
means by which the information can be accessed by the public:
A17.
Does the hospital sponsor quality improvement activities (projects) that provide credit to
physicians for maintenance of certification31 (MOC) Part IV (Performance in Practice)?
[Check all that apply.]
 Yes, the hospital is approved by the ABMS as a multispecialty portfolio program (MSPP)
sponsor
 Yes, the hospital is approved by ABP as a pediatric portfolio sponsor
 Yes, the hospital sponsors one or more projects that are approved by the ABP
 No
31
Certification of quality improvement programs and projects by the American Board of Pediatrics requires a detailed
submission of plans that meet criteria for planning, data collection, measurement and follow-up on quality projects. See:
https://www.aap.org/en-us/continuing-medical-education/mocportfolio/Pages/home.aspx
Last updated: 2/17/2017
A18.
Does your pediatric program have an external review process for determining
patient/parent satisfaction with the care provided by your institution (e.g., surveys, review
committee, etc.) that is conducted on an annual (or more frequent) basis?
 Yes
 No
A18.1 If “yes” to A18, please briefly describe how your pediatric program is externally
reviewed, and 2 (or more) action plans that were developed to address issues
identified in the past calendar year:
A19.
As of January 1, 2017, was your hospital designated a Level 1 or 2 Pediatric Trauma Center
by the American College of Surgeons or by your state licensing board?
 Yes, as a Level 1 Pediatric Trauma Center
 Yes, as a Level 2 Pediatric Trauma Center
 No
A20.
Does your pediatric program currently have an implemented computerized physician order
entry (CPOE) system?
 Yes—Go to Question A21
 No—Skip to Question A22
A21.
Does your implemented (CPOE) system currently provide the following features?
a.
b.
c.
System documents 95% or more of inpatient medication
orders
System identifies orders for medications where there is
a documented allergy to the medication
System includes alerts for dosing errors of high-risk
medications
Yes
No
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A21.1 If “yes” to A21c, please briefly describe 2 current projects with the CPOE system
focused on dosing errors for high-risk medications. In your description, please
mention what problems the system is used to help identify and how you are using
the data to improve the quality of care:
Last updated: 2/17/2017
A22.
Does your pediatric program currently have an implemented electronic medical record
(EMR) system for inpatient care?
 Yes—Go to Question A23
 No—Skip to Question A24
A23.
Does the EMR used by your pediatric program currently provide automated
identification and reporting of “triggers”32 that reflect potential adverse events to
patients?
 Yes
 No
 Not applicable
A23.1 If “yes” to A23, please briefly describe 2 current projects with the EMR system
which use triggers to identify potential adverse events. In your description, please
mention what problems the system is used to help identify and how you are using
the data to improve the quality of care to patients:
A23.2 Does your pediatric program’s electronic medical record system have the ability to
exchange patient health information (e.g., test results, summary of care records)
with other healthcare organizations?
No, we cannot exchange patient health information with other organizations
 Yes, we can exchange patient health information with other organizations that have
the same electronic medical record system vendor (Epic, Cerner, etc.)
 Yes, we can exchange patient health information with other organizations that have a
different electronic medical record system vendor (Epic, Cerner, etc.)
A23.3 Which of the following patient engagement features are currently implemented in
your pediatric program’s electronic medical record system?
a.
b.
c.
d.
Patients have online access to medical notes or records
Patients may request a revision to medical notes or records online
Patients are able to schedule visits online
Patients can send/receive electronic messages to medical
providers)
32
Yes
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No
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Triggers are predetermined flags in an EMR that are used to identify possible adverse events with patients. Some examples
include flags for post-operative complications, nausea following procedures, readmissions, potential adverse drug events, etc.
Last updated: 2/17/2017
A24.
For inpatient care (excluding the Emergency Department), does your pediatric program
audit hand hygiene compliance rates by electronic monitoring or direct observation33
(including secret shoppers) using a tool/form that is standard across your institution?
 Yes, via electronic monitoring or direct observation (including secret shoppers) – Go to
Question A25
 No – Skip to Question A26
A25.
What were the numbers for the total hand hygiene compliance opportunities
completed for the inpatient care areas (excluding Emergency Department) in your
pediatric program in the last calendar year?
Values
a. Number of compliant hand hygiene opportunities observed
________
b. Total number of hand hygiene opportunities observed
________
WARNING:
IF A24=Yes AND A25b = (0 OR BLANK), DISPLAY: “A25b: Please enter a value
greater than 0 or answer No to A24.”
VALIDATE: IF A25x IS NOT A WHOLE NUMBER, DISPLAY: “A25x: Please enter a whole
number (no decimals).”
IF A25a > A25b, DISPLAY: “A25: Please check your responses. The number of
compliant opportunities cannot be greater than the number of opportunities
observed.”
A26.
Does your pediatric program currently provide financial support (e.g., salary support or
contract agreements) for a pediatric infectious disease specialist physician to serve as a
dedicated medical director of your infection prevention program (exclude salary support
for medical director of antimicrobial stewardship or emergency preparedness programs)?
 Yes
 No – Skip to A27
A26.1 Please provide the amount of FTE support for the medical director of your infection
prevention program.
_______ FTE
WARNING:
IF A26=Yes AND A26.1=0, DISPLAY: “If no financial support is provided, you
must answer No to A26.”
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Direct observers (including secret shoppers) are individuals who are trained hand hygiene monitors. This should not include
patient or family observations.
Last updated: 2/17/2017
A27.
How many Infection Preventionist (IP) FTEs do you have in your pediatric program? [If
none, please enter 0.]
________ IP FTEs
SKIP LOGIC: IFA27=0, SKIP TO A28
A27.1. How many of the IP34 who have been in your pediatric program for are certified in
infection control by the Certification Board in Infection Control (CBIC)? [Please
report the number of staff and not a percentage or FTE count.] [If none, please enter 0.]
________ Number of Certified IPs (report # of staff, not FTE)
VALIDATE: IF A27.1 IS NOT A WHOLE NUMBER, DISPLAY: “A27.1: Please enter a whole
number (no decimals).”
A28.
For each of the following categories of health care providers, please indicate if influenza
immunization rates are tracked. If rates are tracked, how many eligible35 health care
providers were continuously employed or providing care between October 1, 2016 and
December 31, 2016? Of those continuously employed or providing care during this time
period, how many received influenza immunization?
Number of
Total Number
Healthcare
of Eligible
Providers Who
Health Care
Received
Influenza immunization
Yes
No
Providers
Immunization
a. Physicians who routinely
practice at your pediatric
facilities (include
________
________
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attendings, fellows, and
residents)
b. Nursing staff and mid-level
providers (e.g. physician
assistants, nurse
________
________
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practitioners) providing
pediatric clinical care
VALIDATE: IF A28x1=Yes AND A28x2=(0 OR BLANK), DISPLAY: “Please provide a value
greater than 0 for eligible providers or answer No to tracking.
IF A28x2 or A28x3 IS NOT A WHOLE NUMBER, DISPLAY: “A28x (Total
Providers / Immunized): Please enter a whole number (no decimals).”
If A28x3 > A28x2, DISPLAY: “A28x: Number of providers receiving immunizations
cannot be greater than total providers.”
34
IPs are typically nurses or medical technicians who play specific roles in hospital infection prevention. Include all IPs, not just
those eligible to sit for certification. The intent of the question is to examine the certification rate of everyone doing the work, not
just those who are eligible.
35 Include staff who refuse immunizations for personal reasons as eligible healthcare providers.
Last updated: 2/17/2017
A29.
For each of the following categories of health care providers, please indicate if the adult
Tdap booster36 (combined Tetanus, Diptheria and Pertussis) immunization rates are
tracked. If rates are tracked, how many eligible health care providers were employed or
providing care as of December 31, 2016. Of this group, how many have evidence of Tdap
vaccination as of December 31, 2016?
Number of
Total Number
Healthcare
of Eligible
Providers Who
Health Care
Had Evidence of
Tdap immunization
Yes
No
Providers
Immunization
a. Physicians who routinely
practice at your pediatric
________
________
○
○
facilities (include attendings,
fellows, and residents)
b. Nursing staff and mid-level
providers (e.g. physician
assistants, nurse
________
________
○
○
practitioners) providing
pediatric clinical care
VALIDATE: IF A29x1=Yes AND A29x2=(0 OR BLANK), DISPLAY: “Please provide a value
greater than 0 for eligible providers or answer No to tracking.
IF A29x2 or A29x3 IS NOT A WHOLE NUMBER, DISPLAY: “A29x (Total
Providers / Immunized): Please enter a whole number (no decimals).”
If A29x3 > A29x2, DISPLAY: “A29x: Number of providers receiving immunizations
cannot be greater than total providers.”
A29.1 Between October 1, 2016 and December 31, 2016, did your pediatric program require all
volunteers to receive or provide documentation of influenza vaccination?
 Yes
 No
A29.2 Does your pediatric program require all volunteers to receive or provide documentation of
Tdap vaccination?
 Yes
 No
A29.3 Does your pediatric program offer an influenza vaccination program for families/primary
caregivers?
 Yes
 No
36
The adult TDaP booster refers to the immunization that has been available since 2005 and does not refer to
childhood immunization
Last updated: 2/17/2017
A29.4 Does your pediatric program offer an adult TDaP booster program for families/primary
caregivers?
 Yes
 No
A30.
Does your pediatric program participate in each of the following quality and safety
programs?
Yes
a. American College of Surgeons (ACS) National Surgical Quality
○
Improvement Program (NSQIP)
b. Children’s Hospital Solutions for Patient Safety learning network
○
(CHSPS)37
c. Vermont Oxford Network or Children’s Hospitals Neonatal Consortium
○
d. Children’s Hospital Association sepsis project
○
e. Other national quality and safety collaborative
○
No
○
○
○
○
○
A30.1 If you answered “yes” to A30e, please list the “other national quality and safety
collaborative” that you are currently participating in. For each organization, please
identify what the focus of the activities your facility has engaged in with the
collaborative over the past year:
A31.
Does your hospital have any of the following elements of an antimicrobial stewardship
program (ASP) currently implemented in your pediatric program?
Yes
No
a. Yearly antimicrobial susceptibility data available to clinicians that is
○
○
specific to pediatric patients and services
b. Pharmacy restricts the use of selected antimicrobials
○
○
38
c. Prospective audit with intervention and feedback has been
○
○
implemented for 2 or more agents and occurs at least 5 days per week
d. At least 0.4 FTE support for a dedicated pharmacist to ASP program
○
○
e. At least 0.3 FTE support for the role of medical director of the pediatric
○
○
ASP program
f. Microbiology laboratory restricts reporting of susceptibilities to some
○
○
antimicrobials to prevent overuse (e.g. Meropenem)
g. At least 0.2 FTE support for a dedicated data analyst to support ASP
○
○
program
h. Formal procedure in place to review the appropriateness of all
○
○
antibiotics 48 hours after the initial orders (e.g. antibiotic time out)
A32.
Does your hospital track hospital-onset respiratory viral infections?
 Yes
 No
This program was previously known as the Ohio Children’s Hospital Solutions for Patient Safety learning network (OCHSPS).
The program focuses on an array of hospital quality measures and is available to hospitals nationally.
38 This should contain the following elements: IV to PO conversion, drug-organism or “drug-bug” susceptibility mismatch, dose
optimization
37
Last updated: 2/17/2017
A33.
Please report your central line-associated bloodstream infection (CLABSI) rates in the last
calendar year for all pediatric ICUs tracked.39 [Calculate as follows: (1) Determine the
number of CLABSI events according to NHSN guidelines.40 (2) Determine the total number of
central line days41 in the last calendar year. (3) Divide CLABSI events by central line days, and
multiply by 1,000. Round your result to 2 decimals.]
________ (1) CLABSI events
________ (2) Central line days
________ (3) CLABSI rate
VALIDATE: IF A33(1) or A33(2) IS NOT A WHOLE NUMBER, DISPLAY: “Please enter a
whole number (no decimals).”
IF A33(1) > A33(2) DISPLAY, “A33: The number of CLABSI events cannot be
greater than the number of central line days.”
AUTOCALC: A33(3) = [(A33(1) / A33(2)) *1000]
A34.
Does your hospital track and report indwelling urinary catheter utilization in your ICU
settings?
 Yes, we track and report for all ICU settings
 Yes, we track and report for some of the ICU settings
 No
A34.1 Does your hospital use any of the following interventions to reduce indwelling urinary
catheter utilization in your ICU settings?
a.
b.
c.
d.
39
Written indications for insertion and/or removal of indwelling urinary
catheters
Automatic removal of urinary catheters following surgery
Bladder scanning
Non-indwelling catheter (e.g., in and out or straight catheter) for
urinary retention
Yes
No
○
○
○
○
○
○
○
○
Exclude numbers from NICU and oncology ICUs.
40
For the most recent NHSN definition of CLABSI, see the following:
http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf. As per these instructions, only include lab-confirmed
CLABSI cases (do not include clinical sepsis).
41 According to NHSN guidelines, a patient with one or more central lines on a given day equals 1 central line day.
Last updated: 2/17/2017
A35.
Does your hospital offer a multidisciplinary Vascular Tumor (or Vascular Anomalies
Program) with representation from pediatric hematology, pediatric surgery, dermatology,
diagnostic pediatric radiology, and pediatric interventional radiology to address vascular
non-malignant tumors?42
 Yes
 No
A36.
Does your pediatric program have a formal program to prevent hospital-acquired pressure
ulcers (see code list)?
 Yes
 No
A37.
Does your pediatric program track the rate of hospital-acquired pressure ulcers (see code
list) for patients seen on an inpatient basis?
 Yes—Go to Question A38.1
 No—Skip to Question A39
 N/A, We treat only NICU patients – Skip to Question A39
A38.1 Please provide the total number of pediatric inpatients in your hospital at the time
of each of your quarterly 1-day surveys or assessments. Of those, how many were
assessed during 1-day surveys or assessments of hospital-acquired pressure ulcers
conducted each quarter in the last calendar year? [Note: If the same patient is present
in multiple quarterly surveys, he/she may be counted only once per quarter. If your
hospital participates in NDNQI or the Nurse Magnet program, please provide numbers
based on your submission to those programs.]
Number of
Number of
pediatric
pediatric
inpatients at the
inpatients assessed
time of assessment
a. Patients from the first quarter (Q1)
_____
_____
b. Patients from the second quarter (Q2)
_____
_____
c. Patients from the third quarter (Q3)
_____
_____
d. Patients from the fourth quarter (Q4)
_____
_____
WARNING:
IF A37=Yes AND A38.1x2 = (0 OR BLANK), DISPLAY: “A38.1x
(Inpatients assessed): Please provide a value greater than 0 for inpatients
assessed or answer No to A37.”
VALIDATE: IF A38.1x IS NOT A WHOLE NUMBER, DISPLAY: “A38.1x: Please enter
a whole number (no decimals).”
If A38.1x2 > A38.1x1, DISPLAY: “The number of inpatients assessed cannot
be greater than the number of inpatients at time of assessment.”
42
This program brings together a multidisciplinary team of specialists to diagnose and ensure the most effective treatment for
optimal functioning and quality of life for children with vascular anomalies (tumors or malformations). To be eligible, a program
must have at least one of each of the following as part of the team: pediatric surgeon, pediatric hematologist/oncologist,
diagnostic radiologist with expertise in vascular anomalies, interventional radiologist with expertise in vascular anomalies,
vascular pathologist, and support from physical or occupational therapy for rehabilitation following vascular surgery.
Last updated: 2/17/2017
A38.2 Of the total pediatric inpatients assessed (sum of Q1 – Q4), how many had
conventional and device-related hospital-acquired pressure ulcers by stage (see code
list)? [Note: For patients assessed in one quarter who have multiple stages of pressure
ulcers (i.e. more than one), assign this patient to the highest stage. If a patient is present
for more than one quarter AND has a stage III, IV, or unstageable pressure ulcer when
assessed, he/she should be included in the count for each quarter in which he/she has an
ulcer.] [If none, please enter 0.]
______ Pediatric inpatients assessed in Q1-Q4 with a stage III pressure ulcer
______ Pediatric inpatients assessed in Q1-Q4 with a stage IV pressure ulcer
______ Pediatric inpatients assessed in Q1-Q4 with an unstageable pressure ulcer
WARNING:
IF A37=Yes AND A38.2x = (BLANK), DISPLAY: “A38.2x: Please provide a
value or answer No to A37. If none, please enter 0.”
VALIDATE: IF A38.2x IS NOT A WHOLE NUMBER, DISPLAY: “A38.2x: Please enter
a whole number (no decimals).”
If A38.2x > (A38.1 inpatients assessed Q1 –Q4), DISPLAY: “A38.2x: The
number of patients with an ulcer cannot be greater than the number of
inpatients assessed (A38.1x).”
A39.
Has your pediatric program engaged in any of the following activities designed to ensure
“high reliability” and safety of all in-patient services to patients? These activities may
occur every 6 months to 2 years.
Yes
No
a. All clinical staff (physicians, nurses, etc.) are trained in code
○
○
response using simulations or other team trainings
b. Trainings include clear instructions and demonstration of roles and
○
○
lines of communication
c. Trainings are video-taped to allow for review of performance and
○
○
needs for improvement
d. Trainings include critical event debriefing or team discussions that
focus on identifying what worked well and where improvement is
○
○
needed
e. Trainings end with the development of an action plan to address
○
○
problems identified during the training or simulation
A39.1 If you answered “yes” to any part of A39, please briefly describe the components of
your pediatric program’s “high reliability” plan. In your response also identify at
least 2 action items that have been identified in the last year that will affect patient
services in the coming year:
Last updated: 2/17/2017
A40.
In which of the following ways are your nurses, physician assistants, nurse practitioners,
and others who provide bedside care encouraged to participate in quality and or safety
initiatives in your pediatric program? Check all that apply.
 Staff are encouraged to conduct mini-Root Cause Analyses (RCA) meetings with paid time
allotted to the effort
 Staff are encouraged to participate in a quality improvement teams with paid time allotted to
the effort
 Staff are expected to participate in quality improvement and safety initiatives, and this is part
of their annual performance evaluation
A41.
Does your pediatric program have a physician serving as a designated Chief Quality Officer
and/or a Chief Safety Officer? If yes, how much of their time is designated to cover this
role?





Yes, > 0.75 FTE
Yes, 0.50-0.74 FTE
Yes, 0.25-0.49 FTE
Yes, < 0.25 FTE
No
The next question is for information purposes only, and will not be used in scoring for the 2017-18
rankings.
A42.
Has your pediatric program reported any of the following rates and data to NHSN?
a.
b.
c.
d.
e.
f.
Central line associated bloodstream infections
Catheter-associated urinary tract infections
Surgical Site Infections
Multidrug resistant organisms/C diff infections
Antimicrobial use
Healthcare Personnel Vaccination
Yes, it is Yes, but it’s
required by not required
the state by the state
○
○
○
○
○
○
○
○
○
○
○
○
No
○
○
○
○
○
○
COMMENTS FOR SECTION A:
If needed, you may provide clarifications to the responses you provided to the questions asked in this
section only. All other comments, suggestions or questions should be sent to
[email protected].
Last updated: 2/17/2017