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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 Q2024_1 and Q2024_4



Unit Name Campus Q2024_1 Q2024_2 Q2024_3 Q2024_4 Total
02N - REHABILITATION UH 0.00 0.00 0.00 0.00 0.00
04B - PSYCHIATRY UH 0.53 0.52 0.00 0.00 0.26
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 0.46 0.12
06B - GENERAL MED/SURG UH 0.00 0.00 0.00 0.00 0.00
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 0.81 0.00 0.00 0.00 0.20
07U - SECURED UNIT UH         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 0.00 0.00 0.00 0.00 0.00
10E - ONCOLOGY UH 0.00 0.41 0.00 0.00 0.10
10G - MEDICINE UH 0.00 0.00 0.00 0.00 0.00
10H - BONE MARROW TRP UNIT UH 0.00 0.00 1.88 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
3W - 3 WEST MEDICAL CC CC 0.44 0.42 0.00 0.00 0.25
4E - 4 EAST PMR CC CC         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 1.16 0.00 0.30
5W - 5 WEST PSYCHIATRY CC CC 0.00 1.05 0.00 0.00 0.28
6thFloor - 6 MED/SURG/ORTHO CC CC 0.00 0.00 0.33 0.00 0.08
EU - EPILEPSY MONITORING UNIT CC CC 0.00 0.00 0.00 0.00 0.00
IC - ICU CC CC 0.00 1.04 0.00 1.91 0.73

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 Q2024_1 and Q2024_4



Unit Name Campus Q2024_1 Q2024_2 Q2024_3 Q2024_4 Total
02N - REHABILITATION UH 3.39 0.00 5.70 0.00 2.35
05A - GEN/ENT/GYN SURGERY UH 0.00 0.00 2.40 3.51 1.46
05B - GENSURG/TRAN/URO/PLA UH 0.00 2.43 0.00 0.00 0.45
06A - MED/PULM/ID/CRITCARE UH 1.72 1.88 2.44 0.00 1.52
06B - GENERAL MED/SURG UH 0.00 0.00 0.00 0.00 0.00
06E - BURN ICU UH 0.00 4.74 0.00 0.00 1.08
06H - MEDICAL ICU UH 0.00 2.29 0.00 0.00 0.51
06I - MEDICAL ICU UH 0.00 1.18 0.00 0.97 0.53
06K - MED/SURG UH 0.00 0.00 0.00 2.00 0.45
07A - ORTHOPEDICS UH 0.00 1.72 0.00 2.07 0.96
07U - SECURED UNIT UH         0.00
08E - SURGICAL ICU UH 1.54 1.69 0.00 0.00 0.81
08F - CARDIOPULMONARY ICU UH 1.24 0.00 0.00 0.00 0.32
08G - CARDIOVASCULAR MED/SURG UH 0.00 0.00 0.00 0.00 0.00
09E - NEUROSCIENCES INTERMED UH 0.00 1.71 1.39 1.45 1.15
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 0.00 0.00
10E - ONCOLOGY UH 1.25 0.67 0.00 0.00 0.48
10G - MEDICINE UH 0.00 0.00 0.00 0.00 0.00
10H - BONE MARROW TRP UNIT UH 0.00 0.00 0.00 0.00 0.00
11E - PEDIATRIC SURGERY UH 0.00 0.00 0.00 0.00 0.00
11G - PEDS HEM/ONC UH 1.49 0.00 0.00 0.00 0.41
12E - PEDIATRICS GENERAL UH 0.00 0.00 0.00 0.00 0.00
12F - PEDIATRIC ICU UH 7.75 0.00 0.00 0.00 1.82
3W - 3 WEST MEDICAL CC CC 2.93 0.00 0.00 0.00 0.96
4E - 4 EAST PMR CC CC         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 0.00
6thFloor - 6 MED/SURG/ORTHO CC CC 2.51 0.00 2.35 0.00 1.28
IC - ICU CC CC 2.15 0.00 0.00 0.00 0.61

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 Q2024_1 and Q2024_4



Unit Name Campus Q2024_1 Q2024_2 Q2024_3 Q2024_4 Total
02N - REHABILITATION UH 0.00 0.00 7.52 0.00 1.83
05A - GEN/ENT/GYN SURGERY UH 3.66 0.00 5.49 0.00 2.42
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 0.00 2.61 0.72
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 0.00 0.00 0.00
06E - BURN ICU UH 0.00 0.00 0.00 0.00 0.00
06H - MEDICAL ICU UH 3.59 1.64 0.00 2.61 2.06
06I - MEDICAL ICU UH 0.00 0.00 0.00 1.33 0.34
06K - MED/SURG UH 0.00 3.89 0.00 0.00 0.96
07A - ORTHOPEDICS UH 1.71 2.38 4.73 2.06 2.61
07U - SECURED UNIT UH         0.00
08E - SURGICAL ICU UH 0.00 1.50 1.63 1.47 1.15
08F - CARDIOPULMONARY ICU UH 0.00 0.00 0.00 6.43 1.78
08G - CARDIOVASCULAR MED/SURG UH 0.00 0.00 2.67 0.00 0.71
09E - NEUROSCIENCES INTERMED UH 5.70 0.00 1.70 1.95 2.30
09F - NEUROSCIENCES ICU UH 1.76 0.00 0.00 1.81 0.87
09G - NEUROSCIENCES M/S UH 5.32 0.00 0.00 0.00 1.35
10E - ONCOLOGY UH 0.00 6.54 0.00 0.00 1.00
10G - MEDICINE UH 0.00 0.00 0.00 6.71 2.70
10H - BONE MARROW TRP UNIT UH 0.00 0.00 0.00 0.00 0.00
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
12F - PEDIATRIC ICU UH 0.00 0.00 5.65 0.00 1.79
3W - 3 WEST MEDICAL CC CC 0.00 0.00 0.00 0.00 0.00
4E - 4 EAST PMR CC CC         0.00
4N - 4 NORTH MED/SURG CC CC 0.00 4.05 0.00 2.17 1.60
4W - 4 WEST MED/SURG CC CC 0.00 0.00 0.00 0.00 0.00
6thFloor - 6 MED/SURG/ORTHO CC CC 0.00 3.85 0.00 0.00 0.79
IC - ICU CC CC 2.11 1.93 1.57 0.00 1.40
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