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 Q2016_3 and Q2017_2



Unit Name Campus Q2016_3 Q2016_4 Q2017_1 Q2017_2 Average
02N - REHABILITATION UH 0.45 0.00 0.00 0.44 0.23
04B - PSYCHIATRY UH 0.00 0.60 0.57 0.00 0.29
05A - GEN/ENT/GYN SURGERY UH 1.10 0.00 0.00 0.00 0.28
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 0.59 0.00 0.14
06E - BURN ICU UH 2.42 0.00 0.00 0.00 0.57
06H - MEDICAL ICU UH 0.77 0.74 0.00 0.00 0.37
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 0.49 0.00 0.00 0.12
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 0.65 0.00 0.00 0.00 0.16
09E - NEUROSCIENCES INTERMED UH 0.94 0.00 0.99 0.00 0.48
09F - NEUROSCIENCES ICU UH 0.00 0.00 0.00 0.88 0.22
09G - NEUROSCIENCES M/S UH 0.00 0.00 0.00 0.70 0.17
10E - ONCOLOGY UH 0.00 0.49 0.46 0.00 0.24
10G - MEDICINE UH 0.00 0.00 0.00 0.98 0.24
10H - BONE MARROW TRP UNIT UH 0.00 0.00 3.94 0.00 1.01
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 0.71 0.63 0.00 0.64 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 0.00
2L - LABOR AND DELIVERY CC CC         0.00
3W - 3 WEST MEDICAL CC CC 1.84 1.27 0.00 0.00 0.74
4E - 4 EAST PMR CC CC 0.00 0.00 0.00 0.00 0.00
4N - 4 NORTH MED/SURG CC CC 0.65 0.00 0.58 0.00 0.30
5W - 5 WEST PSYCHIATRY CC CC 0.00 0.00 0.49 0.49 0.25
6 - 6 MED/SURG/ORTHO CC CC 0.00 0.00 0.00 0.62 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 Q2016_3 and Q2017_2



Unit Name Campus Q2016_3 Q2016_4 Q2017_1 Q2017_2 Average
02N - REHABILITATION UH 0.00 0.00 1.89 0.00 0.74
05A - GEN/ENT/GYN SURGERY UH 0.00 0.00 0.00 0.00 0.00
05B - GENSURG/TRAN/URO/PLA UH 0.00 2.94 0.00 0.00 0.66
06A - MED/PULM/ID/CRITCARE UH 0.00 0.00 0.00 2.54 0.46
06B - GENERAL MED/SURG UH 0.00 0.00 0.00 0.00 0.00
06E - BURN ICU UH 9.17 0.00 0.00 0.00 2.64
06H - MEDICAL ICU UH 0.00 1.26 0.00 0.00 0.31
06I - MEDICAL ICU UH 1.23 0.00 0.00 0.00 0.31
06K - MED/SURG UH 0.00 0.00 2.30 2.31 1.24
07A - ORTHOPEDICS UH 0.00 0.00 0.00 0.00 0.00
08E - SURGICAL ICU UH 3.22 4.23 1.61 1.82 2.80
08F - CARDIOPULMONARY ICU UH 0.00 0.00 0.00 0.00 0.00
08G - CARDIOVASCULAR MED/SURG UH 1.68 0.00 0.00 1.98 0.86
09E - NEUROSCIENCES INTERMED UH 3.94 0.00 0.00 0.00 0.94
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
10G - MEDICINE 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 4.08 0.00 0.00 0.95
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
4N - 4 NORTH MED/SURG CC CC 3.76 0.00 0.00 0.00 1.04
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 Q2016_3 and Q2017_2



Unit Name Campus Q2016_3 Q2016_4 Q2017_1 Q2017_2 Average
02N - REHABILITATION UH 7.30 0.00 0.00 0.00 2.04
05A - GEN/ENT/GYN SURGERY UH 2.83 0.00 0.00 3.47 1.47
05B - GENSURG/TRAN/URO/PLA UH 0.00 0.00 0.00 0.00 0.00
06A - MED/PULM/ID/CRITCARE UH 0.00 1.95 0.00 7.55 1.94
06B - GENERAL MED/SURG UH 0.00 5.68 0.00 0.00 1.65
06E - BURN ICU UH 0.00 0.00 4.17 0.00 1.05
06H - MEDICAL ICU UH 2.22 0.00 0.00 3.53 1.46
06I - MEDICAL ICU UH 3.67 3.44 1.19 0.00 2.13
06K - MED/SURG UH 0.00 0.00 3.65 0.00 0.96
07A - ORTHOPEDICS UH 2.17 0.00 0.00 0.00 0.56
08E - SURGICAL ICU UH 2.37 5.06 3.25 7.67 4.48
08F - CARDIOPULMONARY ICU UH 1.68 3.16 0.00 2.09 1.81
08G - CARDIOVASCULAR MED/SURG UH 2.28 0.00 0.00 0.00 0.82
09E - NEUROSCIENCES INTERMED UH 3.13 2.90 8.66 0.00 3.58
09F - NEUROSCIENCES ICU UH 3.20 2.22 4.90 2.99 3.31
09G - NEUROSCIENCES M/S UH 5.60 0.00 0.00 0.00 1.98
10E - ONCOLOGY UH 0.00 0.00 5.83 0.00 1.68
10G - MEDICINE UH 4.22 0.00 0.00 0.00 1.41
10H - BONE MARROW TRP UNIT UH 10.31 0.00 0.00 0.00 2.75
11G - PEDS HEM/ONC UH 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 4.37 0.00 9.35 2.95
3W - 3 WEST MEDICAL CC CC 0.00 0.00 2.59 0.00 0.89
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 4.59 0.00 0.00 0.95
6 - 6 MED/SURG/ORTHO CC CC 0.00 4.33 0.00 0.00 1.09
IC - ICU CC CC 0.00 7.52 0.00 3.65 3.00