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
02N - REHABILITATION SPECIAL UNIT
04B - PSYCHIATRY SPECIAL UNIT
05A - GEN/ENT/GYN SURGERY MED/SURG
05B - GENSURG/TRAN/URO/PLA MED/SURG
06A - MED/PULM/ID/CRITCARE MED/SURG
06B - GENERAL MED/SURG MED/SURG
06E - BURN ICU ICU
06H - MED ICU ICU
06I - SURG ICU ICU
06K - MED/SURG MED/SURG
07A - ORTHOPEDICS MED/SURG
07U - SECURED UNIT SPECIAL UNIT
08E - CORONARY CARE UNIT ICU
08F - CARDIOPULMONARY ICU ICU
08G - CARDIOVASCULAR MED/SURG MED/SURG
09E - NEUROSCIENCES INTERMED MED/SURG
09F - NEUROSCIENCES ICU ICU
09G - NEUROSCIENCES M/S MED/SURG
10E - ONCOLOGY MED/SURG
10G - MEDICINE MED/SURG
10H - BONE MARROW TRP UNIT MED/SURG
11E - PEDIATRIC SURGERY PEDIATRICS
11G - PEDS HEM/ONC PEDIATRICS
12E - PEDIATRICS/ADOLESCENT PEDIATRICS
12F - PEDIATRIC ICU PEDIATRICS
ED - EMERGENCY DEPARTMENT EMERGENCY

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 Q2014_2 Q2014_3 Q2014_4 Q2015_1 Total
02N - REHABILITATION 0.48 0.44 0.00 0.94 0.46
04B - PSYCHIATRY 0.00 0.00 0.56 0.00 0.14
05A - GEN/ENT/GYN SURGERY 1.73 0.00 0.00 0.50 0.53
05B - GENSURG/TRAN/URO/PLA 0.00 0.00 0.52 0.00 0.14
06A - MED/PULM/ID/CRITCARE 0.00 0.00 0.00 1.05 0.27
06B - GENERAL MED/SURG 0.00 0.00 1.78 0.00 0.43
06E - BURN ICU 2.06 0.00 0.00 0.00 0.55
06H - MED ICU 0.74 0.00 0.00 0.00 0.20
06I - SURG ICU 1.56 0.00 0.00 0.00 0.41
06K - MED/SURG 0.79 0.00 0.00 0.00 0.19
06L - ORTHOPEDICS 0.00 0.00 0.00 0.00 0.00
07A - ORTHOPEDICS 0.00 0.00 0.00 0.00 0.00
07U - SECURED UNIT 0.00 0.00 0.00 0.00 0.00
08E - CORONARY CARE UNIT 0.00 0.00 0.00 0.00 0.00
08F - CARDIOPULMONARY ICU 0.00 0.00 0.00 0.00 0.00
08G - CARDIOVASCULAR MED/SURG 0.66 0.61 0.00 0.63 0.47
09E - NEUROSCIENCES INTERMED 0.00 1.94 0.00 0.97 0.73
09F - NEUROSCIENCES ICU 0.00 0.00 0.00 0.00 0.00
09G - NEUROSCIENCES M/S 0.75 0.80 0.00 0.00 0.37
10E - ONCOLOGY 0.00 0.45 0.84 0.00 0.33
10G - MEDICINE 0.97 1.89 0.87 0.88 1.14
10H - BONE MARROW TRP UNIT 0.00 0.00 0.00 0.00 0.00
11E - PEDIATRIC SURGERY 2.38 0.00 0.79 0.61 0.89
11G - PEDS HEM/ONC 0.00 1.25 0.00 1.13 0.64
12E - PEDIATRICS/ADOLESCENT 2.29 0.00 0.00 0.00 2.29
12F - PEDIATRIC ICU 0.00 0.00 0.00 0.00 0.00

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 Q2013_3 and Q2014_2



Unit Name Q2013_3 Q2013_4 Q2014_1 Q2014_2 Total
02N - REHABILITATION 0.00% 4.00% 0.00% 0.00% 1.16%
04B - PSYCHIATRY 0.00% 0.00% 0.00% 0.00% 0.00%
05A - GEN/ENT/GYN SURGERY 0.00% 0.00% 0.00% 4.76% 1.25%
05B - GENSURG/TRAN/URO/PLA 0.00% 0.00% 0.00% 0.00% 0.00%
06A - MED/PULM/ID/CRITCARE 0.00% 0.00% 0.00% 0.00% 0.00%
06B - GENERAL MED/SURG 10.00% 0.00% 0.00% 0.00% 4.08%
06E - BURN ICU 0.00% 0.00% 0.00% 20.00% 5.00%
06H - MED ICU 13.33% 21.43% 0.00% 0.00% 8.62%
06I - SURG ICU 12.50% 6.67% 15.38% 7.14% 10.34%
06K - MED/SURG 0.00% 0.00% 0.00% 0.00% 0.00%
06L - ORTHOPEDICS 0.00% 0.00% 4.00% 0.00% 1.61%
07A - ORTHOPEDICS 0.00% 0.00% 4.00% 0.00% 1.61%
07U - SECURED UNIT 0.00% 0.00% 0.00% 0.00% 0.00%
08E - CORONARY CARE UNIT 16.67% 9.09% 7.69% 7.69% 10.20%
08F - CARDIOPULMONARY ICU 0.00% 0.00% 0.00% 8.33% 2.00%
08G - CARDIOVASCULAR MED/SURG 5.88% 0.00% 0.00% 0.00% 1.64%
09E - NEUROSCIENCES INTERMED 0.00% 0.00% 0.00% 0.00% 0.00%
09F - NEUROSCIENCES ICU 0.00% 7.14% 0.00% 0.00% 1.96%
09G - NEUROSCIENCES M/S 0.00% 0.00% 0.00% 0.00% 0.00%
10E - ONCOLOGY 0.00% 7.41% 3.70% 0.00% 2.86%
10G - MEDICINE 0.00% 0.00% 0.00% 0.00% 0.00%
10H - BONE MARROW TRP UNIT 0.00% 0.00% 0.00% 0.00% 0.00%
11E - PEDIATRIC SURGERY 0.00% 0.00% 0.00% 0.00% 0.00%
11G - PEDS HEM/ONC 0.00% 0.00% 0.00% 0.00% 0.00%
12E - PEDIATRICS/ADOLESCENT 0.00% 0.00% 0.00% 0.00% 0.00%
12F - PEDIATRIC ICU 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) is 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 Q2014_2 Q2014_3 Q2014_4 Q2015_1 Total
06E - BURN ICU 0.00 0.00 0.00 5.49 1.42
06F - CP ICU 0.00 0.00 0.00 0.00 0.00
06H - MED ICU 3.98 0.00 0.00 0.00 0.71
06I - SURG ICU 0.00 0.00 0.00 0.00 0.00
08E - CORONARY CARE UNIT 0.00 0.00 0.00 0.00 0.00
08F - CARDIOPULMONARY ICU 0.00 0.00 1.64 0.00 0.47
09E - NEUROSCIENCES INTERMED 0.00 0.00 0.00 0.00 0.00
09F - NEUROSCIENCES ICU 0.00 0.00 0.00 0.00 0.00
12F - PEDIATRIC ICU 0.00 0.00 0.00 0.00 0.00