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
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
5E - 5 EAST TRANSITIONAL CARE CC SPECIAL UNIT CC
5W - 5 WEST PSYCHIATRY CC SPECIAL UNIT CC
6 - 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 Q2018_2 and Q2019_1



Unit Name Campus Q2018_2 Q2018_3 Q2018_4 Q2019_1 Total
02N - REHABILITATION UH 0.00 0.42 0.00 0.00 0.11
04B - PSYCHIATRY UH 0.55 0.54 0.00 0.00 0.28
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 0.53 0.14
06A - MED/PULM/ID/CRITCARE UH 0.00 0.50 0.00 0.51 0.26
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 2.23 0.00 0.00 0.00 0.55
06K - MED/SURG UH 0.00 0.00 0.00 0.75 0.18
07A - ORTHOPEDICS UH 0.00 0.00 0.00 0.00 0.00
07U - SECURED UNIT UH 0.00 1.66 0.00 0.00 0.50
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 0.69 0.67 0.00 0.65 0.50
09E - NEUROSCIENCES INTERMED UH 0.94 0.00 0.00 0.00 0.23
09F - NEUROSCIENCES ICU UH 0.00 0.00 0.00 0.00 0.00
09G - NEUROSCIENCES M/S UH 0.00 0.00 0.66 0.64 0.34
10E - ONCOLOGY UH 0.00 0.00 0.00 1.29 0.32
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 1.98 0.50
11E - PEDIATRIC SURGERY UH 0.00 0.00 0.00 0.67 0.18
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
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
3W - 3 WEST MEDICAL CC CC 0.00 0.57 1.14 1.03 0.69
4E - 4 EAST PMR CC CC 0.00 0.00 1.22 1.15 0.53
4N - 4 NORTH MED/SURG CC CC 0.55 0.00 0.58 0.00 0.28
5W - 5 WEST PSYCHIATRY CC CC 0.00 0.49 1.09 0.00 0.38
6 - 6 MED/SURG/ORTHO CC CC 0.60 0.00 0.00 0.53 0.29
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 Q2018_2 and Q2019_1



Unit Name Campus Q2018_2 Q2018_3 Q2018_4 Q2019_1 Total
02N - REHABILITATION UH 0.00 1.77 0.00 4.12 1.50
05A - GEN/ENT/GYN SURGERY UH 0.00 0.00 1.87 0.00 0.53
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 0.00 2.34 0.49
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 0.00 1.13 1.14 0.00 0.66
06I - MEDICAL ICU UH 0.00 1.07 1.10 0.00 0.62
06K - MED/SURG UH 0.00 0.00 0.00 0.00 0.00
07A - ORTHOPEDICS UH 0.00 2.39 2.19 0.00 1.18
08E - SURGICAL ICU UH 0.00 0.00 1.52 0.00 0.43
08F - CARDIOPULMONARY ICU UH 0.00 0.00 1.36 0.00 0.41
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 1.22 0.00 2.38 0.71
09G - NEUROSCIENCES M/S UH 0.00 0.00 0.00 0.00 0.00
10G - MEDICINE UH 0.00 0.00 2.12 0.00 0.57
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
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 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 5.85 0.00 4.26 0.00 2.44
IC - ICU CC CC 5.29 4.52 0.00 0.00 2.57

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 Q2018_2 and Q2019_1



Unit Name Campus Q2018_2 Q2018_3 Q2018_4 Q2019_1 Total
02N - REHABILITATION UH 0.00 16.39 0.00 6.45 5.48
05A - GEN/ENT/GYN SURGERY UH 3.70 0.00 5.52 0.00 2.47
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 0.00 0.00 0.00
06A - MED/PULM/ID/CRITCARE UH 3.23 8.75 0.00 0.00 3.59
06B - GENERAL MED/SURG UH 3.82 3.28 0.00 14.49 4.21
06E - BURN ICU UH 9.90 0.00 0.00 0.00 2.67
06H - MEDICAL ICU UH 0.00 0.00 2.73 2.06 1.06
06I - MEDICAL ICU UH 0.00 1.23 2.89 0.00 1.05
06K - MED/SURG UH 0.00 3.39 3.80 0.00 2.04
07A - ORTHOPEDICS UH 0.00 2.31 0.00 0.00 0.72
08E - SURGICAL ICU UH 3.12 1.63 0.00 4.75 2.23
08F - CARDIOPULMONARY ICU UH 2.09 0.00 1.73 0.00 1.05
08G - CARDIOVASCULAR MED/SURG UH 0.00 0.00 0.00 0.00 0.00
09E - NEUROSCIENCES INTERMED UH 6.58 3.82 0.00 0.00 2.63
09F - NEUROSCIENCES ICU UH 5.56 6.53 1.45 2.34 4.23
09G - NEUROSCIENCES M/S UH 0.00 9.13 6.21 7.46 5.94
10E - ONCOLOGY UH 0.00 3.13 0.00 0.00 1.13
10G - MEDICINE UH 6.94 6.37 0.00 0.00 3.82
10H - BONE MARROW TRP UNIT UH 0.00 25.64 0.00 0.00 5.62
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
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 0.00
4N - 4 NORTH MED/SURG CC CC 0.00 0.00 2.82 9.01 2.39
6 - 6 MED/SURG/ORTHO CC CC 0.00 0.00 15.54 0.00 3.31
IC - ICU CC CC 0.00 0.00 0.00 0.00 0.00
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