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Nursing Quality Measures

Nurse Staffing Actual

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 NameUnit TypeCampus
02N - REHABILITATIONSPECIAL UNITUH
04B - PSYCHIATRYSPECIAL UNITUH
05A - GEN/ENT/GYN SURGERYMED/SURGUH
05B - GENSURG/TRAN/URO/PLAMED/SURGUH
06A - MED/PULM/ID/CRITCAREMED/SURGUH
06B - GENERAL MED/SURGMED/SURGUH
06E - BURN ICUICUUH
06H - MEDICAL ICUICUUH
06I - MEDICAL ICUICUUH
06K - MED/SURGMED/SURGUH
07A - ORTHOPEDICSMED/SURGUH
07U - SECURED UNITSPECIAL UNITUH
08E - SURGICAL ICUICUUH
08F - CARDIOPULMONARY ICUICUUH
08G - CARDIOVASCULAR MED/SURGMED/SURGUH
09E - NEUROSCIENCES INTERMEDMED/SURGUH
09F - NEUROSCIENCES ICUICUUH
09G - NEUROSCIENCES M/SMED/SURGUH
10E - ONCOLOGYMED/SURGUH
10G - MEDICINE MED/SURGUH
10H - BONE MARROW TRP UNITMED/SURGUH
11E - PEDIATRIC SURGERYPEDIATRICSUH
11G - PEDS HEM/ONCPEDIATRICSUH
12E - PEDIATRICS GENERALPEDIATRICSUH
12F - PEDIATRIC ICUPEDIATRICSUH
ERMADULT - EMERGENCY DEPARTMENTEMERGENCYUH
ERMPED - PEDIATRIC EMERGENCY DEPARTMENTEMERGENCYUH
2E - 2 EAST OB/GYN CCMED/SURGCC
3W - 3 WEST MEDICAL CCMED/SURGCC
4E - 4 EAST PMR CCSPECIAL UNITCC
4N - 4 NORTH MED/SURG CCMED/SURGCC
5E - 5 EAST TRANSITIONAL CARE CCSPECIAL UNITCC
5W - 5 WEST PSYCHIATRY CCSPECIAL UNITCC
6 - 6 MED/SURG/ORTHO CCMED/SURGCC
ED - EMERGENCY DEPARTMENT CCEMERGENCYCC
EU - EPILEPSY MONITORING UNIT CCMED/SURGCC
IC - ICU CCICUCC

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 NameCampusQ2018_4Q2019_1Q2019_2Q2019_3Total
02N - REHABILITATIONUH0.000.000.880.440.34
04B - PSYCHIATRYUH0.590.001.130.000.43
05A - GEN/ENT/GYN SURGERYUH0.000.000.000.500.13
05B - GENSURG/TRAN/URO/PLAUH0.000.530.000.000.14
06A - MED/PULM/ID/CRITCAREUH0.000.510.540.000.26
06B - GENERAL MED/SURGUH0.530.540.001.610.68
06E - BURN ICUUH0.000.000.000.000.00
06H - MEDICAL ICUUH0.000.000.000.000.00
06I - MEDICAL ICUUH0.000.000.000.000.00
06K - MED/SURGUH0.000.750.750.000.37
07A - ORTHOPEDICSUH0.000.000.000.000.00
07U - SECURED UNITUH0.000.002.180.000.50
08E - SURGICAL ICUUH0.000.000.000.000.00
08F - CARDIOPULMONARY ICUUH0.000.000.000.000.00
08G - CARDIOVASCULAR MED/SURGUH0.001.960.000.000.50
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH0.000.000.880.000.21
09G - NEUROSCIENCES M/SUH0.661.280.000.000.50
10E - ONCOLOGYUH0.431.720.870.440.86
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH0.001.980.000.000.49
11E - PEDIATRIC SURGERYUH0.001.330.001.290.68
11G - PEDS HEM/ONCUH1.090.000.002.390.85
12E - PEDIATRICS GENERALUH0.000.610.001.270.48
12F - PEDIATRIC ICUUH0.000.000.000.000.00
2E - 2 EAST OB/GYN CCCC0.000.000.000.00
2L - LABOR AND DELIVERY CCCC0.00
3W - 3 WEST MEDICAL CCCC1.711.550.000.530.95
4E - 4 EAST PMR CCCC1.221.150.003.171.42
4N - 4 NORTH MED/SURG CCCC0.580.000.550.000.27
5W - 5 WEST PSYCHIATRY CCCC1.640.510.000.480.63
6 - 6 MED/SURG/ORTHO CCCC0.000.530.530.000.28
EU - EPILEPSY MONITORING UNIT CCCC0.000.000.000.000.00
IC - ICU CCCC0.001.501.870.000.82

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 NameCampusQ2018_4Q2019_1Q2019_2Q2019_3Total
02N - REHABILITATIONUH0.000.000.000.000.00
05A - GEN/ENT/GYN SURGERYUH1.870.000.000.000.51
05B - GENSURG/TRAN/URO/PLAUH0.001.773.550.001.52
06A - MED/PULM/ID/CRITCAREUH0.000.000.000.000.00
06B - GENERAL MED/SURGUH0.000.000.000.000.00
06E - BURN ICUUH0.000.000.0012.742.31
06H - MEDICAL ICUUH1.140.001.330.000.67
06I - MEDICAL ICUUH0.001.090.000.000.32
06K - MED/SURGUH0.000.000.005.971.12
07A - ORTHOPEDICSUH2.190.000.000.000.64
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH1.520.000.000.000.45
08F - CARDIOPULMONARY ICUUH1.361.300.000.000.68
08G - CARDIOVASCULAR MED/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH0.001.560.000.000.39
09G - NEUROSCIENCES M/SUH0.000.003.450.000.80
10E - ONCOLOGYUH1.330.000.660.000.55
10G - MEDICINE UH2.120.000.003.441.15
10H - BONE MARROW TRP UNITUH0.002.352.450.001.34
11E - PEDIATRIC SURGERYUH5.380.000.007.633.37
11G - PEDS HEM/ONCUH1.573.032.120.001.94
12E - PEDIATRICS GENERALUH0.000.000.000.000.00
12F - PEDIATRIC ICUUH0.000.000.003.830.69
3W - 3 WEST MEDICAL CCCC0.000.000.000.000.00
4E - 4 EAST PMR CCCC0.000.000.000.000.00
4N - 4 NORTH MED/SURG CCCC0.003.600.000.000.82
5W - 5 WEST PSYCHIATRY CCCC0.000.000.000.000.00
6 - 6 MED/SURG/ORTHO CCCC4.260.003.795.953.26
IC - ICU CCCC0.000.000.000.000.00

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 NameCampusQ2018_4Q2019_1Q2019_2Q2019_3Total
02N - REHABILITATIONUH0.0012.9011.3631.7511.93
05A - GEN/ENT/GYN SURGERYUH5.520.000.000.001.16
05B - GENSURG/TRAN/URO/PLAUH0.000.000.000.000.00
06A - MED/PULM/ID/CRITCAREUH0.000.000.000.000.00
06B - GENERAL MED/SURGUH0.0017.390.000.004.77
06E - BURN ICUUH0.000.006.370.001.52
06H - MEDICAL ICUUH2.731.341.440.001.49
06I - MEDICAL ICUUH2.891.281.490.001.53
06K - MED/SURGUH3.800.003.120.002.14
07A - ORTHOPEDICSUH0.000.000.004.740.75
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH0.004.980.005.212.34
08F - CARDIOPULMONARY ICUUH1.731.552.940.001.75
08G - CARDIOVASCULAR MED/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH1.453.051.657.713.24
09G - NEUROSCIENCES M/SUH6.214.520.000.002.62
10E - ONCOLOGYUH0.000.000.000.000.00
10G - MEDICINE UH0.000.006.130.001.81
10H - BONE MARROW TRP UNITUH0.000.000.000.000.00
11E - PEDIATRIC SURGERYUH0.000.000.000.000.00
11G - PEDS HEM/ONCUH0.000.000.000.000.00
12E - PEDIATRICS GENERALUH0.000.000.000.000.00
12F - PEDIATRIC ICUUH0.000.000.006.291.86
3W - 3 WEST MEDICAL CCCC0.000.000.000.000.00
4E - 4 EAST PMR CCCC0.000.000.000.000.00
4N - 4 NORTH MED/SURG CCCC2.825.750.004.053.09
6 - 6 MED/SURG/ORTHO CCCC15.540.000.000.003.47
IC - ICU CCCC0.000.000.006.451.63
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