Hospital Safety Grades Show Significant Variation

Heidi Splete

November 15, 2021

Approximately one third of acute care hospitals in the United States earned an "A" grade for patient safety, according to the Fall 2021 Leapfrog Hospital Safety Grade report, a quality check on a hospital's ability to protect patients from preventable errors, accidents, infections, and injuries.

The Fall 2021 Hospital Safety Grade assigned grades to 2901 general acute care hospitals. Overall, 32% of the hospitals received an A grade, 26% received a B, 35% received a C, 7% received a D, and less than 1% received an F. The states were ranked in order of their percentage of A-grade hospitals. States with the highest percentages of A-grade hospitals were Virginia (56.2%), North Carolina (55.1%), Idaho (53.9%), Massachusetts (51.7%), and Colorado 48.8%). At the other end of the spectrum, no hospitals in Delaware, North Dakota, or Washington, DC, earned an A grade.

The Leapfrog Group, a nonprofit organization, was founded in 2000 by large employers and other purchasers focused on healthcare safety. The organization's goal is to support quality and safety in healthcare in the United States. The semiannual Leapfrog Hospital Safety Grade assigns letter grades of A to F to acute care hospitals across the country. The Fall 2021 report was based on 22 measures, and marks the first-time inclusion of post-operative sepsis, blood leakage, and falls that can lead to hip injury.

"The fall grades show significant variation in patient safety performance across US hospitals, which underscores the importance of access to information that allows patients to select the safest hospital available to them," according to a press release from The Leapfrog Group announcing the results.

The Leapfrog Hospital Safety Grade methodology is based on national patient safety measures from the Centers for Medicare & Medicaid Services, as well as from the Leapfrog Hospital Survey and other supplemental data sources. The survey is voluntary and offered annually for free to all eligible hospitals in the United States. "In some cases where a hospital's information is not available for a certain measure, Leapfrog uses a supplemental data source," according to the Hospital Safety Grade website. "In cases where a hospital's information is not available from any data source, Leapfrog has outlined a methodology for dealing with the missing data." The methodology has been peer reviewed and published in the Journal of Patient Safety. The patient safety measures included two domains, process/structural measures and outcome measures; each accounted for 50% of the grade.

The process/structural measures included computerized physician order entry, bar code medication administration, and ICU physician staffing. This category also included three safe practice measures: Culture of Leadership Structures and Systems; Culture Measurement, Feedback & Intervention; and Nursing Workforce. Additional measures included hand hygiene, doctor and nurse communication, staff responsiveness, communication about medicines, and discharge information.

Process measures were defined as how often a hospital provides the recommended treatment for a medical condition or procedure. "For example, 'Responsiveness of hospital staff' looks at patients' feedback on how long it takes for a staff member to respond when they request help," according to the website. Structural measures involve the patient care environment. An example of structural measures is whether doctors order medications through a computer as an indicator of whether a hospital uses a specialized computer system to prevent prescribing errors.

The 10 outcome measures that factored into the safety grades were foreign object retained, air embolism, falls and trauma, central line-associated bloodstream infection, catheter-associated urinary tract infections, surgical-site infections from colon surgery, methicillin-resistant Staphylococcus aureus events, Clostridioides difficile infections, Patient Safety Indicator 4 (death rate among surgical inpatients with serious treatable conditions), and CMS Medicare Patient Safety Indicator 90 (a patient safety and adverse events composite). Outcome measures represent the patient's experience while receiving care and how often certain events occurred. For example, the measure of foreign object retention indicates how many times a dangerous foreign object, such as a sponge or tool, was left in the body of a patient who underwent surgery.

"As the pandemic continues, we all have heightened awareness of the importance of hospitals in our communities and in our lives," said Leah Binder, president and CEO of The Leapfrog Group, in the press release. "It is critical that all hospitals put patient safety first," and the dissemination of hospital safety information can help patients make informed decisions about their care, she said.

The Leapfrog Group is currently unable to assign grades to other categories of hospitals, including military or VA hospitals, critical access hospitals, specialty hospitals, children's hospitals, and outpatient surgery centers, but the organization is exploring ways to grade these facilities in the future, according to the website.

The Leapfrog Hospital Safety Grade receives advice from an expert panel of patient safety authorities from across the country, and from the Johns Hopkins Armstrong Institute for Patient Safety and Quality. More information about the Safety Grade and details about individual hospital grades are available online at

J Patient Saf. 2021;17:445-450. Abstract

Heidi Splete is a freelance medical journalist with 20 years of experience.

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