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 - MEDICAL ICU ICU UH
06I - MEDICAL ICU ICU UH
06K - MED/SURG MED/SURG UH
07A - ORTHOPEDICS MED/SURG UH
07U - SECURED UNIT SPECIAL UNIT UH
08E - SURGICAL 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
ERMADULT - EMERGENCY DEPARTMENT EMERGENCY UH
ERMPED - PEDIATRIC EMERGENCY DEPARTMENT EMERGENCY UH
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
5E - 5 EAST TRANSITIONAL CARE CC SPECIAL UNIT CC
5W - 5 WEST PSYCHIATRY CC SPECIAL UNIT CC
6thFloor - 6 MED/SURG/ORTHO CC MED/SURG CC
ED - EMERGENCY DEPARTMENT CC EMERGENCY 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 Q2021_1 and Q2021_4



Unit Name Campus Q2021_1 Q2021_2 Q2021_3 Q2021_4 Total
02N - REHABILITATION UH 0.45 0.00 0.44 0.00 0.23
04B - PSYCHIATRY UH 0.00 0.00 0.60 0.00 0.14
05A - GEN/ENT/GYN SURGERY UH 0.00 0.00 0.00 0.00 0.00
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 0.00 0.00 0.00
06A - MED/PULM/ID/CRITCARE UH 0.00 0.00 0.00 0.00 0.00
06B - GENERAL MED/SURG UH 0.50 0.49 0.00 0.00 0.25
06E - BURN ICU UH 0.00 0.00 0.00 0.00 0.00
06H - MEDICAL ICU UH 0.00 0.00 0.00 0.00 0.00
06I - MEDICAL ICU UH 0.00 0.00 0.00 0.00 0.00
06K - MED/SURG UH 0.00 0.00 0.00 0.00 0.00
07A - ORTHOPEDICS UH 0.00 0.00 0.00 0.47 0.11
07U - SECURED UNIT UH 0.00 0.00 0.00   0.00
08E - SURGICAL 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 0.00 0.00 0.00 0.00 0.00
09E - NEUROSCIENCES INTERMED UH 0.00 0.00 0.00 0.00 0.00
09F - NEUROSCIENCES ICU UH 0.00 0.00 0.00 0.00 0.00
09G - NEUROSCIENCES M/S UH 0.62 0.00 1.19 0.00 0.45
10E - ONCOLOGY UH 0.00 0.00 0.00 0.00 0.00
10G - MEDICINE UH 0.00 0.00 0.00 0.00 0.00
10H - BONE MARROW TRP UNIT UH 0.00 1.90 0.00 0.00 0.47
11E - PEDIATRIC SURGERY UH 0.00 0.00 0.00 0.00 0.00
11G - PEDS HEM/ONC UH 0.00 0.00 0.00 0.00 0.00
12E - PEDIATRICS GENERAL UH 0.00 0.00 0.00 0.00 0.00
12F - PEDIATRIC ICU UH 0.00 0.00 0.00 0.00 0.00
2 - 2 POSTPARTUM GYN CC CC         0.00
2L - LABOR AND DELIVERY CC CC 0.00 0.00     0.00
3W - 3 WEST MEDICAL CC CC 0.00 0.00 0.00 0.00 0.00
4E - 4 EAST PMR CC CC 0.00 1.02 1.71   0.74
4N - 4 NORTH MED/SURG CC CC 0.00 0.00 0.91 0.00 0.24
4W - 4 WEST MED/SURG CC CC 0.00 0.00 0.00 0.00 0.00
5W - 5 WEST PSYCHIATRY CC CC 0.00 0.00 0.00 0.00 0.00
6thFloor - 6 MED/SURG/ORTHO CC CC 0.42 0.00 0.00 0.00 0.09
EU - EPILEPSY MONITORING UNIT 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

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 Q2021_1 and Q2021_4



Unit Name Campus Q2021_1 Q2021_2 Q2021_3 Q2021_4 Total
02N - REHABILITATION UH 0.00 0.00 1.79 0.00 0.49
05A - GEN/ENT/GYN SURGERY UH 0.00 0.00 0.00 0.00 0.00
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 0.00 0.00 0.00
06A - MED/PULM/ID/CRITCARE UH 0.00 0.00 0.00 0.00 0.00
06B - GENERAL MED/SURG UH 0.00 0.00 1.42 0.00 0.41
06E - BURN ICU UH 0.00 0.00 0.00 7.43 1.92
06H - MEDICAL ICU UH 0.00 0.97 0.00 0.88 0.48
06I - MEDICAL ICU UH 1.03 0.00 0.00 1.16 0.55
06K - MED/SURG UH 0.00 0.00 0.00 0.00 0.00
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
08E - SURGICAL ICU UH 0.00 0.00 1.55 0.00 0.39
08F - CARDIOPULMONARY ICU UH 0.00 0.00 0.00 0.00 0.00
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 0.00 0.00
09F - NEUROSCIENCES ICU UH 1.16 0.00 0.00 0.00 0.36
09G - NEUROSCIENCES M/S UH 1.92 0.00 0.00 2.42 1.06
10E - ONCOLOGY UH 0.00 1.39 0.61 0.66 0.66
10G - MEDICINE UH 0.00 0.00 0.00   0.00
10H - BONE MARROW TRP UNIT UH 2.15 0.00 2.04 8.32 3.23
11E - PEDIATRIC SURGERY UH 0.00 0.00 0.00 0.00 0.00
11G - PEDS HEM/ONC UH 0.00 0.00 0.00 0.00 0.00
12E - PEDIATRICS GENERAL UH 7.35 0.00 0.00 0.00 3.10
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 0.00 0.00
4E - 4 EAST PMR CC CC 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
4W - 4 WEST MED/SURG CC CC 0.00 0.00 0.00 0.00 0.00
5W - 5 WEST PSYCHIATRY CC CC 0.00 0.00     0.00
6thFloor - 6 MED/SURG/ORTHO CC CC 0.00 0.00 0.00 1.73 0.62
IC - ICU CC CC 0.00 0.00 0.00 1.46 0.48

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 Q2021_1 and Q2021_4



Unit Name Campus Q2021_1 Q2021_2 Q2021_3 Q2021_4 Total
02N - REHABILITATION UH 0.00 0.00 11.90 14.18 7.14
05A - GEN/ENT/GYN SURGERY UH 0.00 0.00 0.00 0.00 0.00
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 2.86 0.00 0.76
06A - MED/PULM/ID/CRITCARE UH 3.02 0.00 0.00 5.21 2.07
06B - GENERAL MED/SURG UH 0.00 0.00 0.00 0.00 0.00
06E - BURN ICU UH 14.49 10.36 0.00 0.00 6.68
06H - MEDICAL ICU UH 4.43 2.29 2.53 3.88 3.29
06I - MEDICAL ICU UH 1.09 0.00 1.23 4.08 1.51
06K - MED/SURG UH 0.00 0.00 0.00 3.65 0.89
07A - ORTHOPEDICS UH 0.00 0.00 4.87 0.00 1.37
07U - SECURED UNIT UH 0.00 0.00 0.00   0.00
08E - SURGICAL ICU UH 0.00 3.11 1.46 3.17 1.88
08F - CARDIOPULMONARY ICU UH 1.35 0.00 1.37 0.00 0.75
08G - CARDIOVASCULAR MED/SURG UH 5.09 0.00 0.00 0.00 1.87
09E - NEUROSCIENCES INTERMED UH 1.61 4.71 0.00 8.62 3.47
09F - NEUROSCIENCES ICU UH 1.35 5.63 1.97 4.63 3.16
09G - NEUROSCIENCES M/S UH 3.61 6.37 5.10 0.00 3.78
10E - ONCOLOGY UH 0.00 0.00 0.00 4.42 0.82
10G - MEDICINE UH 0.00 0.00 0.00   0.00
10H - BONE MARROW TRP UNIT UH 16.39 12.66 12.66 0.00 11.90
11E - PEDIATRIC SURGERY UH 0.00 0.00 0.00 0.00 0.00
11G - PEDS HEM/ONC UH 0.00 0.00 0.00 0.00 0.00
12E - PEDIATRICS GENERAL UH 0.00 0.00 0.00 0.00 0.00
12F - PEDIATRIC ICU UH 9.01 0.00 0.00 0.00 2.41
3W - 3 WEST MEDICAL CC CC 0.00 0.00 0.00 0.00 0.00
4E - 4 EAST PMR CC CC   0.00 0.00   0.00
4N - 4 NORTH MED/SURG CC CC 0.00 0.00 2.93 0.00 0.75
4W - 4 WEST MED/SURG CC CC 0.00 0.00 10.10 0.00 1.64
6thFloor - 6 MED/SURG/ORTHO CC CC 0.00 7.75 5.52 2.31 3.56
IC - ICU CC CC 0.00 0.00 2.06 1.85 1.00
Top