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 Q2015_4 and Q2016_3



Unit Name Campus Q2015_4 Q2016_1 Q2016_2 Q2016_3 Average
02N - REHABILITATION UH 0.00 0.00 0.00 0.45 0.12
04B - PSYCHIATRY UH 0.00 0.00 0.00 0.00 0.00
05A - GEN/ENT/GYN SURGERY UH 0.00 0.61 0.00 1.10 0.45
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 0.00 0.00 0.00
06A - MED/PULM/ID/CRITCARE UH 0.55 0.00 0.00 0.00 0.14
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 2.42 0.57
06H - MEDICAL ICU UH 0.00 0.00 0.00 0.77 0.21
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 0.53 0.00 0.00 0.13
07U - SECURED UNIT UH 0.00 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 0.68 1.29 0.50
09E - NEUROSCIENCES INTERMED UH 0.00 0.00 0.00 0.94 0.25
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 0.68 0.19
10E - ONCOLOGY UH 0.46 1.41 0.00 0.00 0.49
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 0.73 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 0.71 0.17
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 0.00 0.00 1.84 0.45
4E - 4 EAST PMR CC CC 0.00 0.00 0.00 0.00 0.00
4N - 4 NORTH MED/SURG CC CC 0.70 0.00 0.00 1.30 0.48
5W - 5 WEST PSYCHIATRY CC CC 0.00 0.52 0.00 0.00 0.13
6 - 6 MED/SURG/ORTHO CC CC 0.00 0.61 0.00 0.00 0.16
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

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_3 and Q2015_2



Unit Name Campus Q2014_3 Q2014_4 Q2015_1 Q2015_2 Average
02N - REHABILITATION UH 0.00% 0.00% 0.00% 0.00% 0.00%
05A - GEN/ENT/GYN SURGERY UH 0.00% 0.00% 4.17% 0.00% 1.06%
05B - GENSURG/TRAN/URO/PLA UH 4.76% 0.00% 4.76% 7.14% 3.75%
06A - MED/PULM/ID/CRITCARE UH 0.00% 0.00% 5.26% 9.09% 3.53%
06B - GENERAL MED/SURG UH 5.56% 0.00% 0.00% 5.13% 3.26%
06E - BURN ICU UH     0.00% 0.00% 0.00%
06H - MEDICAL ICU UH 13.33% 7.14% 6.67% 18.18% 10.91%
06I - MEDICAL ICU UH     46.15% 6.67% 25.00%
06K - MED/SURG UH 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% 0.00%
08E - SURGICAL ICU UH 0.00% 9.09% 20.00% 33.33% 15.22%
08F - CARDIOPULMONARY ICU UH 0.00% 8.33% 7.69% 0.00% 4.08%
08G - CARDIOVASCULAR MED/SURG UH 0.00% 0.00% 0.00%   0.00%
09E - NEUROSCIENCES INTERMED UH 0.00% 0.00% 7.69% 0.00% 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% 0.00%
10E - ONCOLOGY UH 0.00% 0.00% 0.00% 0.00% 0.00%
10G - MEDICINE UH 8.33% 0.00% 0.00% 8.33% 4.08%
10H - BONE MARROW TRP UNIT UH 0.00% 0.00% 0.00% 0.00% 0.00%
11E - PEDIATRIC SURGERY UH         0.00%
11G - PEDS HEM/ONC UH         0.00%
12E - PEDIATRICS GENERAL UH         0.00%
12F - PEDIATRIC ICU UH         0.00%
3W - 3 WEST MEDICAL CC CC 4.55% 0.00% 3.70% 0.00% 2.20%
4E - 4 EAST PMR CC CC 0.00% 0.00% 0.00% 6.25% 2.17%
4N - 4 NORTH MED/SURG CC CC 0.00% 3.85% 3.70% 0.00% 2.30%
6 - 6 MED/SURG/ORTHO CC CC 0.00% 6.25% 3.85%   3.28%
IC - ICU CC CC 16.67% 0.00% 14.29% 16.67% 12.00%

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 Q2015_4 and Q2016_3



Unit Name Campus Q2015_4 Q2016_1 Q2016_2 Q2016_3 Average
02N - REHABILITATION UH 0.00 0.00 0.00 0.00 0.00
05A - GEN/ENT/GYN SURGERY UH 1.84 0.00 0.00 0.00 0.56
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 2.17 0.00 0.53
06A - MED/PULM/ID/CRITCARE UH 3.62 0.00 0.00 0.00 0.78
06B - GENERAL MED/SURG UH 0.00 0.00 0.00 0.00 0.00
06E - BURN ICU UH 3.53 3.13 0.00 9.17 3.69
06H - MEDICAL ICU UH 1.28 1.17 0.00 0.00 0.60
06I - MEDICAL ICU UH 0.00 1.15 0.00 1.23 0.61
06K - MED/SURG UH 0.00 1.96 0.00 0.00 0.55
07A - ORTHOPEDICS UH 0.00 0.00 0.00 0.00 0.00
08E - SURGICAL ICU UH 0.00 2.77 0.00 3.22 1.51
08F - CARDIOPULMONARY ICU UH 0.00 4.40 3.71 0.00 1.83
08G - CARDIOVASCULAR MED/SURG UH 0.00 0.00 0.00 1.68 0.43
09E - NEUROSCIENCES INTERMED UH 0.00 0.00 0.00 3.94 0.86
09F - NEUROSCIENCES ICU UH 1.26 0.00 2.61 0.00 0.92
09G - NEUROSCIENCES M/S UH 0.00 2.18 0.00 0.00 0.61
10G - MEDICINE UH 0.00 2.91 3.62 0.00 1.61
12E - PEDIATRICS GENERAL UH 0.00 0.00 4.61 0.00 1.99
12F - PEDIATRIC ICU UH 0.00 3.13 4.08 0.00 1.84
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 3.76 0.91
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 Q2015_4 and Q2016_3



Unit Name Campus Q2015_4 Q2016_1 Q2016_2 Q2016_3 Average
02N - REHABILITATION UH 0.00 8.85 0.00 7.30 4.65
05A - GEN/ENT/GYN SURGERY UH 2.49 0.00 0.00 2.83 1.40
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 2.48 0.00 0.54
06A - MED/PULM/ID/CRITCARE UH 0.00 2.11 0.00 0.00 0.66
06B - GENERAL MED/SURG UH 0.00 0.00 0.00 0.00 0.00
06E - BURN ICU UH 10.31 3.09 0.00 0.00 3.54
06H - MEDICAL ICU UH 2.48 0.00 3.24 2.22 2.00
06I - MEDICAL ICU UH 1.22 1.08 0.00 3.67 1.48
06K - MED/SURG UH 0.00 0.00 3.39 0.00 0.84
07A - ORTHOPEDICS UH 1.95 0.00 0.00 2.17 1.03
08E - SURGICAL ICU UH 6.27 0.00 0.00 2.37 2.18
08F - CARDIOPULMONARY ICU UH 1.99 1.81 3.54 1.68 2.26
08G - CARDIOVASCULAR MED/SURG UH 0.00 3.21 0.00 2.28 1.45
09E - NEUROSCIENCES INTERMED UH 0.00 0.00 0.00 3.13 0.76
09F - NEUROSCIENCES ICU UH 4.81 4.11 2.45 3.20 3.65
09G - NEUROSCIENCES M/S UH 0.00 0.00 0.00 5.60 1.46
10E - ONCOLOGY UH 2.54 0.00 3.03 0.00 1.47
10G - MEDICINE UH 0.00 9.35 0.00 4.22 3.25
10H - BONE MARROW TRP UNIT UH 0.00 0.00 0.00 10.31 4.24
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 2.54 0.00 0.00 0.83
4E - 4 EAST PMR CC CC 0.00 250.00 0.00 0.00 22.73
4N - 4 NORTH MED/SURG CC CC 0.00 0.00 0.00 0.00 0.00
6 - 6 MED/SURG/ORTHO CC CC 3.24 0.00 0.00 0.00 0.97
IC - ICU CC CC 0.00 0.00 0.00 0.00 0.00