Nursing Quality Measures

Staffing Data

What this means:
Number of Nursing Staff - Number of RN's, LPN's and HCT providing direct nursing care.

Percent of Nursing Staff - Number of RN's, LPN's and HCT providing direct nursing care / Total number of RN's, LPN's and HCT's providing direct nursing care.

Nursing hours per patient day (NHPPD) - Number of hours of direct care a patient can expect to receive from an RN, LPN, HCT, in a 24-hour period.

RN Hours Per Patient Day (RNHPPD) - Number of hours of direct care a patient can expect to receive from and RN in a 24-hour period.

Nurse : Patient Ratio - Number of patients cared for by one nurse; calculated as 24 / RN Hours Per Patient Day.

Click on a unit below to see its Staffing Actual

Unit Name Unit Type Campus
02N - REHABILITATION SPECIAL UNIT UH
04B - PSYCHIATRY SPECIAL UNIT UH
05A - GEN/ENT/GYN SURGERY MED/SURG UH
05B - GENSURG/TRAN/URO/PLA MED/SURG UH
06A - MED/PULM/ID/CRITCARE MED/SURG UH
06B - GENERAL MED/SURG MED/SURG UH
06E - BURN ICU ICU UH
06H - MED ICU ICU UH
06I - MED ICU ICU UH
06K - MED/SURG MED/SURG UH
07A - ORTHOPEDICS MED/SURG UH
07U - SECURED UNIT SPECIAL UNIT UH
08E - SURG ICU ICU UH
08F - CARDIOPULMONARY ICU ICU UH
08G - CARDIOVASCULAR MED/SURG MED/SURG UH
09E - NEUROSCIENCES INTERMED MED/SURG UH
09F - NEUROSCIENCES ICU ICU UH
09G - NEUROSCIENCES M/S MED/SURG UH
10E - ONCOLOGY MED/SURG UH
10G - MEDICINE MED/SURG UH
10H - BONE MARROW TRP UNIT MED/SURG UH
11E - PEDIATRIC SURGERY PEDIATRICS UH
11G - PEDS HEM/ONC PEDIATRICS UH
12E - PEDIATRICS GENERAL PEDIATRICS UH
12F - PEDIATRIC ICU PEDIATRICS UH
ED - EMERGENCY DEPARTMENT EMERGENCY UH
2E - 2 EAST OB/GYN CC MED/SURG CC
3W - 3 WEST MEDICAL CC MED/SURG CC
4E - 4 EAST PMR CC SPECIAL UNIT CC
4N - 4 NORTH MED/SURG CC MED/SURG CC
4W - 4 WEST MED/SURG CC MED/SURG CC
5W - 5 WEST PSYCHIATRY CC SPECIAL UNIT CC
6 - 6 MED/SURG/ORTHO CC MED/SURG CC
ED - EMERGENCY DEPARTMENT CC BOARDING CC
EU - EPILEPSY MONITORING UNIT CC MED/SURG CC
IC - ICU CC ICU CC

Patient Falls with Injury


What this means:
All documented patient falls with an injury level of moderate or greater.

Moderate - resulted in suturing, application of steri-strips/skin glue, or splinting.

Falls with injury rate = # of falls w/ injury of moderate or greater severity / Patient Days * 1000

Data for the period between Q2014_2 and Q2015_1



Unit Name Campus Q2014_2 Q2014_3 Q2014_4 Q2015_1 Total
02N - REHABILITATION UH 0.48 0.44 0.00 0.94 0.46
04B - PSYCHIATRY UH 0.00 0.00 0.56 0.00 0.14
05A - GEN/ENT/GYN SURGERY UH 1.74 0.00 0.00 0.50 0.53
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 0.52 0.00 0.14
06A - MED/PULM/ID/CRITCARE UH 0.00 0.00 0.00 1.05 0.27
06B - GENERAL MED/SURG UH 0.00 0.00 1.78 0.00 0.44
06E - BURN ICU UH 2.07 0.00 0.00 0.00 0.55
06H - MED ICU UH 0.74 0.00 0.00 0.00 0.20
06I - MED ICU UH 1.56 0.00 0.00 0.00 0.41
06K - MED/SURG UH 0.80 0.00 0.00 0.00 0.19
07A - ORTHOPEDICS UH 0.00 0.00 0.00 0.00 0.00
07U - SECURED UNIT UH 0.00 0.00 0.00 0.00 0.00
08E - SURG ICU UH 0.00 0.00 0.00 0.00 0.00
08F - CARDIOPULMONARY ICU UH 0.00 0.00 0.00 0.00 0.00
08G - CARDIOVASCULAR MED/SURG UH 0.67 0.61 0.00 0.63 0.47
09E - NEUROSCIENCES INTERMED UH 0.00 1.94 0.00 0.97 0.73
09F - NEUROSCIENCES ICU UH 0.00 0.00 0.00 0.00 0.00
09G - NEUROSCIENCES M/S UH 0.77 0.80 0.00 0.00 0.37
10E - ONCOLOGY UH 0.00 0.45 0.84 0.00 0.33
10G - MEDICINE UH 0.98 1.89 0.87 0.88 1.14
10H - BONE MARROW TRP UNIT UH 0.00 0.00 0.00 0.00 0.00
11E - PEDIATRIC SURGERY UH 2.43 0.00 0.79 0.61 0.89
11G - PEDS HEM/ONC UH 0.00 1.25 0.00 1.13 0.64
12E - PEDIATRICS GENERAL UH 0.76 0.00 0.00 0.00 0.18
12F - PEDIATRIC ICU UH 0.00 0.00 0.00 0.00 0.00
2E - 2 EAST OB/GYN CC CC 0.00 0.00 0.00 0.00 0.00
2L - LABOR AND DELIVERY CC CC 0.00       0.00
3W - 3 WEST MEDICAL CC CC 0.00 1.16 0.00 0.00 0.26
4E - 4 EAST PMR CC CC 2.22 0.97 0.00 2.07 1.31
4N - 4 NORTH MED/SURG CC CC 1.85 0.00 1.61 0.00 0.84
5W - 5 WEST PSYCHIATRY CC CC 0.50 1.49 1.53 0.48 0.99
6 - 6 MED/SURG/ORTHO CC CC 0.60 0.00 0.00 0.00 0.14
EU - EPILEPSY MONITORING UNIT CC CC 0.00 0.00 0.00 8.06 2.49
IC - ICU CC CC 1.95 0.00 0.00 0.00 0.47

Pressure Ulcer Stage


What this means:
The total number of patients that have nosocomial (hospital-acquired) stage II or greater pressure ulcers on the day of the prevalence study. A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear and/or friction. A less-specific, general term for pressure ulcers is bed sores.

Nosocomial pressure ulcer stage 2 or above rate = # of patients with a facility acquired pressure ulcer stage 2 or above / # of patients assessed * 1000

Data for the period between Q2014_2 and Q2015_1



Unit Name Campus Q2014_2 Q2014_3 Q2014_4 Q2015_1 Total
02N - REHABILITATION UH 0.00% 0.00% 0.00% 0.00% 0.00%
05A - GEN/ENT/GYN SURGERY UH 4.76% 0.00% 0.00% 4.17% 2.22%
05B - GENSURG/TRAN/URO/PLA UH   4.76% 0.00% 4.76% 3.03%
06A - MED/PULM/ID/CRITCARE UH   0.00% 0.00% 5.26% 1.59%
06B - GENERAL MED/SURG UH   5.56% 0.00% 0.00% 1.89%
06E - BURN ICU UH 20.00%     0.00% 10.00%
06H - MED ICU UH 0.00% 13.33% 7.14% 6.67% 7.02%
06I - MED ICU UH 7.14%     46.15% 25.93%
06K - MED/SURG UH 0.00% 0.00% 0.00% 0.00% 0.00%
07A - ORTHOPEDICS UH     4.00% 3.33% 3.64%
07U - SECURED UNIT UH   0.00% 0.00%   0.00%
08E - SURG ICU UH 7.69% 0.00% 9.09% 20.00% 8.51%
08F - CARDIOPULMONARY ICU UH 8.33% 0.00% 8.33% 7.69% 6.12%
08G - CARDIOVASCULAR MED/SURG UH 0.00% 0.00% 0.00% 0.00% 0.00%
09E - NEUROSCIENCES INTERMED UH 0.00% 0.00% 0.00% 7.69% 1.96%
09F - NEUROSCIENCES ICU UH 0.00% 0.00% 0.00% 0.00% 0.00%
09G - NEUROSCIENCES M/S UH   0.00%   0.00% 0.00%
10E - ONCOLOGY UH 0.00% 0.00% 0.00% 0.00% 0.00%
10G - MEDICINE UH 0.00% 8.33% 0.00% 0.00% 2.08%
10H - BONE MARROW TRP UNIT UH   0.00% 0.00% 0.00% 0.00%
11E - PEDIATRIC SURGERY UH 0.00%       0.00%
11G - PEDS HEM/ONC UH         0.00%
12E - PEDIATRICS GENERAL UH 0.00%       0.00%
12F - PEDIATRIC ICU UH         0.00%

Central Line Infections


What this means:
The rate of CLABSI for ICU Locations. Central line associated blood stream infection (CLABSI) as defined as a bloodstream infection thought to have been caused by the presence of a central line.

Central line associated blood stream infections (CLABSI) in ICU patients = # of CLABSI's / # of central line days * 1000

Data for the period between Q2014_2 and Q2015_1



Unit Name Campus Q2014_2 Q2014_3 Q2014_4 Q2015_1 Total
02N - REHABILITATION UH       0.00 0.00
05A - GEN/ENT/GYN SURGERY UH       1.63 1.63
05B - GENSURG/TRAN/URO/PLA UH       1.61 1.61
06A - MED/PULM/ID/CRITCARE UH       2.39 2.39
06B - GENERAL MED/SURG UH       0.00 0.00
06E - BURN ICU UH 0.00 0.00 0.00 5.49 1.34
06H - MED ICU UH 2.61 0.00 0.00 0.00 0.65
06I - MED ICU UH 0.00 0.00 0.00 0.00 0.00
06K - MED/SURG UH       1.81 1.81
07A - ORTHOPEDICS UH       0.00 0.00
08E - SURG ICU UH 0.00 0.00 0.00 0.00 0.00
08F - CARDIOPULMONARY ICU UH 0.00 0.00 1.64 0.00 0.43
08G - CARDIOVASCULAR MED/SURG UH       0.00 0.00
09E - NEUROSCIENCES INTERMED UH       0.00 0.00
09F - NEUROSCIENCES ICU UH 0.00 0.00 0.00 0.00 0.00
09G - NEUROSCIENCES M/S UH       3.31 3.31
10G - MEDICINE UH       0.00 0.00
12E - PEDIATRICS GENERAL UH       0.00 0.00
12F - PEDIATRIC ICU UH 0.00 0.00 0.00 0.00 0.00
3W - 3 WEST MEDICAL CC CC 0.00 0.00 0.00 11.24 3.00
4E - 4 EAST PMR CC CC 0.00 0.00 0.00 0.00 0.00
4N - 4 NORTH MED/SURG CC CC 0.00 0.00 0.00 0.00 0.00
6 - 6 MED/SURG/ORTHO CC CC 0.00 0.00 0.00 0.00 0.00
IC - ICU CC CC 0.00 0.00 0.00 0.00 0.00

Catheter associated UTI


What this means:
The rate of Catheter associated UTIs for ICU Locations. Catheter associated urinary tract infection (CAUTI) as defined as a urinary tract infection thought to have been caused by an indwelling urinary catheter.

Catheter associated urinary tract infections (CAUTI) in ICU patients = # of CAUTI's / # of foley catheter days * 1000

Data for the period between Q2014_2 and Q2015_1



Unit Name Campus Q2014_2 Q2014_3 Q2014_4 Q2015_1 Total
02N - REHABILITATION UH 4.50 5.62 4.69 2.21 3.75
05A - GEN/ENT/GYN SURGERY UH       1.13 1.13
05B - GENSURG/TRAN/URO/PLA UH       1.04 1.04
06A - MED/PULM/ID/CRITCARE UH       1.67 1.67
06B - GENERAL MED/SURG UH       1.87 1.87
06E - BURN ICU UH 5.26 5.41 6.71 0.00 4.21
06H - MED ICU UH 2.44 2.24 1.71 1.08 1.86
06I - MED ICU UH 3.15 0.00 7.30 1.01 2.83
06K - MED/SURG UH       3.38 3.38
07A - ORTHOPEDICS UH       1.10 1.10
08E - SURG ICU UH 1.53 1.48 1.34 3.25 2.00
08F - CARDIOPULMONARY ICU UH 5.85 4.67 2.16 0.00 2.81
08G - CARDIOVASCULAR MED/SURG UH       0.00 0.00
09E - NEUROSCIENCES INTERMED UH       1.92 1.92
09F - NEUROSCIENCES ICU UH 4.76 2.51 2.66 2.27 3.06
09G - NEUROSCIENCES M/S UH       4.62 4.62
10E - ONCOLOGY UH       2.55 2.55
10G - MEDICINE UH       2.72 2.72
10H - BONE MARROW TRP UNIT UH       0.00 0.00
11G - PEDS HEM/ONC UH       0.00 0.00
12E - PEDIATRICS GENERAL UH       0.00 0.00
12F - PEDIATRIC ICU UH 0.00 0.00 0.00 0.00 0.00
3W - 3 WEST MEDICAL CC CC 4.19 3.52 3.16 0.00 2.60
4E - 4 EAST PMR CC CC 0.00 0.00 0.00 0.00 0.00
4N - 4 NORTH MED/SURG CC CC 5.13 0.00 0.00 0.00 1.21
6 - 6 MED/SURG/ORTHO CC CC 0.00 0.00 0.00 2.33 0.74
IC - ICU CC CC 5.70 2.79 0.00 2.39 2.56