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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 Q2021_3 and Q2022_2



Unit Name Campus Q2021_3 Q2021_4 Q2022_1 Q2022_2 Total
02N - REHABILITATION UH 0.44 0.00 0.00 0.00 0.11
04B - PSYCHIATRY UH 0.60 0.00 0.00 0.00 0.17
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 0.00 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 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 0.71 0.18
07A - ORTHOPEDICS UH 0.00 0.47 0.00 0.47 0.23
07U - SECURED UNIT UH 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 0.00 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 1.19 0.00 0.00 0.59 0.45
10E - ONCOLOGY UH 0.00 0.00 0.00 0.00 0.00
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 0.00 0.00 1.10 0.00 0.27
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 0.00 0.00 0.00 0.00 0.00
4E - 4 EAST PMR CC CC 1.71       1.71
4N - 4 NORTH MED/SURG CC CC 0.91 0.00 0.00 0.00 0.25
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 0.69 0.14
6thFloor - 6 MED/SURG/ORTHO CC CC 0.00 0.00 0.00 0.00 0.00
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 Q2021_3 and Q2022_2



Unit Name Campus Q2021_3 Q2021_4 Q2022_1 Q2022_2 Total
02N - REHABILITATION UH 1.79 0.00 0.00 0.00 0.60
05A - GEN/ENT/GYN SURGERY UH 0.00 0.00 2.00 0.00 0.50
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 0.00 1.63 0.45
06A - MED/PULM/ID/CRITCARE UH 0.00 0.00 0.00 0.00 0.00
06B - GENERAL MED/SURG UH 1.42 0.00 2.00 0.00 0.82
06E - BURN ICU UH 0.00 7.43 0.00 0.00 1.83
06H - MEDICAL ICU UH 0.00 0.88 0.00 0.00 0.25
06I - MEDICAL ICU UH 0.00 1.16 0.00 0.00 0.29
06K - MED/SURG UH 0.00 0.00 0.00 0.00 0.00
07A - ORTHOPEDICS UH 0.00 0.00 0.00 0.00 0.00
07U - SECURED UNIT UH 0.00       0.00
08E - SURGICAL ICU UH 1.55 0.00 0.00 0.00 0.42
08F - CARDIOPULMONARY ICU UH 0.00 0.00 0.00 0.00 0.00
08G - CARDIOVASCULAR MED/SURG UH 0.00 0.00 2.39 0.00 0.52
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 2.42 0.00 0.00 0.54
10E - ONCOLOGY UH 0.61 0.66 0.66 2.12 0.98
10G - MEDICINE UH 0.00   0.00   0.00
10H - BONE MARROW TRP UNIT UH 2.04 8.32 2.14 0.00 3.15
11E - PEDIATRIC SURGERY UH 0.00 0.00 0.00 3.31 1.26
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 5.21 0.00 0.00 0.00 1.07
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
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
6thFloor - 6 MED/SURG/ORTHO CC CC 0.00 1.73 0.00 0.00 0.62
IC - ICU CC CC 0.00 1.46 0.00 0.00 0.47

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 Q2021_3 and Q2022_2



Unit Name Campus Q2021_3 Q2021_4 Q2022_1 Q2022_2 Total
02N - REHABILITATION UH 11.90 14.18 0.00 11.76 8.85
05A - GEN/ENT/GYN SURGERY UH 0.00 0.00 3.85 0.00 0.86
05B - GENSURG/TRAN/URO/PLA UH 2.86 0.00 3.44 0.00 1.68
06A - MED/PULM/ID/CRITCARE UH 0.00 5.21 0.00 0.00 1.13
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 6.90 1.36
06H - MEDICAL ICU UH 2.53 3.88 0.00 1.63 2.11
06I - MEDICAL ICU UH 1.23 4.08 1.36 0.00 1.75
06K - MED/SURG UH 0.00 3.65 0.00 0.00 1.06
07A - ORTHOPEDICS UH 4.87 0.00 0.00 2.60 2.13
07U - SECURED UNIT UH 0.00       0.00
08E - SURGICAL ICU UH 1.46 3.17 0.00 0.00 1.24
08F - CARDIOPULMONARY ICU UH 1.37 0.00 4.40 0.00 1.35
08G - CARDIOVASCULAR MED/SURG UH 0.00 0.00 0.00 0.00 0.00
09E - NEUROSCIENCES INTERMED UH 0.00 8.62 0.00 0.00 2.28
09F - NEUROSCIENCES ICU UH 1.97 4.63 2.03 2.02 2.59
09G - NEUROSCIENCES M/S UH 5.10 0.00 0.00 0.00 1.21
10E - ONCOLOGY UH 0.00 4.42 0.00 0.00 0.88
10G - MEDICINE UH 0.00   0.00   0.00
10H - BONE MARROW TRP UNIT UH 12.66 0.00 0.00 0.00 4.83
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 7.25 2.01
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
4N - 4 NORTH MED/SURG CC CC 2.93 0.00 0.00 0.00 0.76
4W - 4 WEST MED/SURG CC CC 10.10 0.00 0.00 0.00 1.51
6thFloor - 6 MED/SURG/ORTHO CC CC 5.52 2.31 3.60 0.00 2.86
IC - ICU CC CC 2.06 1.85 0.00 0.00 1.00
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