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_4 and Q2019_3



Unit Name Campus Q2018_4 Q2019_1 Q2019_2 Q2019_3 Total
02N - REHABILITATION UH 0.00 0.00 0.88 0.44 0.34
04B - PSYCHIATRY UH 0.59 0.00 1.13 0.00 0.43
05A - GEN/ENT/GYN SURGERY UH 0.00 0.00 0.00 0.50 0.13
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.53 0.00 0.00 0.14
06A - MED/PULM/ID/CRITCARE UH 0.00 0.51 0.54 0.00 0.26
06B - GENERAL MED/SURG UH 0.53 0.54 0.00 1.61 0.68
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 0.75 0.75 0.00 0.37
07A - ORTHOPEDICS UH 0.00 0.00 0.00 0.00 0.00
07U - SECURED UNIT UH 0.00 0.00 2.18 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 0.00 1.96 0.00 0.00 0.50
09E - NEUROSCIENCES INTERMED UH 0.00 0.00 0.00 0.00 0.00
09F - NEUROSCIENCES ICU UH 0.00 0.00 0.88 0.00 0.21
09G - NEUROSCIENCES M/S UH 0.66 1.28 0.00 0.00 0.50
10E - ONCOLOGY UH 0.43 1.72 0.87 0.44 0.86
10G - MEDICINE UH 0.00 0.00 0.00 0.00 0.00
10H - BONE MARROW TRP UNIT UH 0.00 1.98 0.00 0.00 0.49
11E - PEDIATRIC SURGERY UH 0.00 1.33 0.00 1.29 0.68
11G - PEDS HEM/ONC UH 1.09 0.00 0.00 2.39 0.85
12E - PEDIATRICS GENERAL UH 0.00 0.61 0.00 1.27 0.48
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
2L - LABOR AND DELIVERY CC CC         0.00
3W - 3 WEST MEDICAL CC CC 1.71 1.55 0.00 0.53 0.95
4E - 4 EAST PMR CC CC 1.22 1.15 0.00 3.17 1.42
4N - 4 NORTH MED/SURG CC CC 0.58 0.00 0.55 0.00 0.27
5W - 5 WEST PSYCHIATRY CC CC 1.64 0.51 0.00 0.48 0.63
6 - 6 MED/SURG/ORTHO CC CC 0.00 0.53 0.53 0.00 0.28
EU - EPILEPSY MONITORING UNIT CC CC 0.00 0.00 0.00 0.00 0.00
IC - ICU CC CC 0.00 1.50 1.87 0.00 0.82

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_4 and Q2019_3



Unit Name Campus Q2018_4 Q2019_1 Q2019_2 Q2019_3 Total
02N - REHABILITATION UH 0.00 0.00 0.00 0.00 0.00
05A - GEN/ENT/GYN SURGERY UH 1.87 0.00 0.00 0.00 0.51
05B - GENSURG/TRAN/URO/PLA UH 0.00 1.77 3.55 0.00 1.52
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 12.74 2.31
06H - MEDICAL ICU UH 1.14 0.00 1.33 0.00 0.67
06I - MEDICAL ICU UH 0.00 1.09 0.00 0.00 0.32
06K - MED/SURG UH 0.00 0.00 0.00 5.97 1.12
07A - ORTHOPEDICS UH 2.19 0.00 0.00 0.00 0.64
07U - SECURED UNIT UH 0.00 0.00 0.00 0.00 0.00
08E - SURGICAL ICU UH 1.52 0.00 0.00 0.00 0.45
08F - CARDIOPULMONARY ICU UH 1.36 1.30 0.00 0.00 0.68
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 1.56 0.00 0.00 0.39
09G - NEUROSCIENCES M/S UH 0.00 0.00 3.45 0.00 0.80
10E - ONCOLOGY UH 1.33 0.00 0.66 0.00 0.55
10G - MEDICINE UH 2.12 0.00 0.00 3.44 1.15
10H - BONE MARROW TRP UNIT UH 0.00 2.35 2.45 0.00 1.34
11E - PEDIATRIC SURGERY UH 5.38 0.00 0.00 7.63 3.37
11G - PEDS HEM/ONC UH 1.57 3.03 2.12 0.00 1.94
12E - PEDIATRICS GENERAL UH 0.00 0.00 0.00 0.00 0.00
12F - PEDIATRIC ICU UH 0.00 0.00 0.00 3.83 0.69
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 3.60 0.00 0.00 0.82
5W - 5 WEST PSYCHIATRY CC CC 0.00 0.00 0.00 0.00 0.00
6 - 6 MED/SURG/ORTHO CC CC 4.26 0.00 3.79 5.95 3.26
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 Q2018_4 and Q2019_3



Unit Name Campus Q2018_4 Q2019_1 Q2019_2 Q2019_3 Total
02N - REHABILITATION UH 0.00 12.90 11.36 31.75 11.93
05A - GEN/ENT/GYN SURGERY UH 5.52 0.00 0.00 0.00 1.16
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 17.39 0.00 0.00 4.77
06E - BURN ICU UH 0.00 0.00 6.37 0.00 1.52
06H - MEDICAL ICU UH 2.73 1.34 1.44 0.00 1.49
06I - MEDICAL ICU UH 2.89 1.28 1.49 0.00 1.53
06K - MED/SURG UH 3.80 0.00 3.12 0.00 2.14
07A - ORTHOPEDICS UH 0.00 0.00 0.00 4.74 0.75
07U - SECURED UNIT UH 0.00 0.00 0.00 0.00 0.00
08E - SURGICAL ICU UH 0.00 4.98 0.00 5.21 2.34
08F - CARDIOPULMONARY ICU UH 1.73 1.55 2.94 0.00 1.75
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 1.45 3.05 1.65 7.71 3.24
09G - NEUROSCIENCES M/S UH 6.21 4.52 0.00 0.00 2.62
10E - ONCOLOGY UH 0.00 0.00 0.00 0.00 0.00
10G - MEDICINE UH 0.00 0.00 6.13 0.00 1.81
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 0.00
12F - PEDIATRIC ICU UH 0.00 0.00 0.00 6.29 1.86
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 2.82 5.75 0.00 4.05 3.09
6 - 6 MED/SURG/ORTHO CC CC 15.54 0.00 0.00 0.00 3.47
IC - ICU CC CC 0.00 0.00 0.00 6.45 1.63
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