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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_3 and Q2019_2

Unit NameCampusQ2018_3Q2018_4Q2019_1Q2019_2Total
02N - REHABILITATIONUH0.420.000.000.000.11
04B - PSYCHIATRYUH0.540.000.001.130.42
05A - GEN/ENT/GYN SURGERYUH0.000.000.000.000.00
05B - GENSURG/TRAN/URO/PLAUH0.000.000.000.000.00
06A - MED/PULM/ID/CRITCAREUH0.500.000.000.540.26
06B - GENERAL MED/SURGUH0.000.000.000.000.00
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/SURGUH0.000.000.000.000.00
07A - ORTHOPEDICSUH0.000.000.000.000.00
07U - SECURED UNITUH0.000.000.002.180.50
08E - SURGICAL ICUUH0.000.000.000.000.00
08F - CARDIOPULMONARY ICUUH0.000.000.000.000.00
08G - CARDIOVASCULAR MED/SURGUH0.670.000.000.000.17
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH0.000.000.000.000.00
09G - NEUROSCIENCES M/SUH0.000.660.000.000.17
10E - ONCOLOGYUH0.000.001.720.440.54
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH0.000.001.980.000.50
11E - PEDIATRIC SURGERYUH0.000.000.670.000.18
11G - PEDS HEM/ONCUH0.000.000.000.000.00
12E - PEDIATRICS GENERALUH0.000.000.000.000.00
12F - PEDIATRIC ICUUH0.000.000.000.000.00
2E - 2 EAST OB/GYN CCCC0.000.000.000.000.00
2L - LABOR AND DELIVERY CCCC0.00
3W - 3 WEST MEDICAL CCCC0.570.571.030.000.55
4E - 4 EAST PMR CCCC0.001.221.150.000.55
4N - 4 NORTH MED/SURG CCCC0.000.580.000.000.14
5W - 5 WEST PSYCHIATRY CCCC0.490.550.000.000.25
6 - 6 MED/SURG/ORTHO CCCC0.000.000.530.000.14
EU - EPILEPSY MONITORING UNIT CCCC0.000.000.000.000.00
IC - ICU CCCC0.000.000.001.870.42

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_3 and Q2019_2

Unit NameCampusQ2018_3Q2018_4Q2019_1Q2019_2Total
02N - REHABILITATIONUH1.770.000.000.000.52
05A - GEN/ENT/GYN SURGERYUH0.001.870.000.000.46
05B - GENSURG/TRAN/URO/PLAUH0.000.001.773.551.38
06A - MED/PULM/ID/CRITCAREUH0.000.000.000.000.00
06B - GENERAL MED/SURGUH0.000.000.000.000.00
06E - BURN ICUUH0.000.000.000.000.00
06H - MEDICAL ICUUH1.131.140.001.330.92
06I - MEDICAL ICUUH1.070.001.090.000.56
06K - MED/SURGUH0.000.000.000.000.00
07A - ORTHOPEDICSUH2.392.190.000.001.13
08E - SURGICAL ICUUH0.001.520.000.000.42
08F - CARDIOPULMONARY ICUUH0.001.361.300.000.67
08G - CARDIOVASCULAR MED/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH1.220.001.560.000.70
09G - NEUROSCIENCES M/SUH0.000.000.003.450.71
10G - MEDICINE UH0.002.120.000.000.52
12E - PEDIATRICS GENERALUH0.000.000.000.000.00
12F - PEDIATRIC ICUUH0.000.000.000.000.00
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 CCCC0.000.003.600.000.85
6 - 6 MED/SURG/ORTHO CCCC0.004.260.003.792.07
IC - ICU CCCC4.520.000.000.001.02

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_3 and Q2019_2

Unit NameCampusQ2018_3Q2018_4Q2019_1Q2019_2Total
02N - REHABILITATIONUH16.390.0012.9011.3610.46
05A - GEN/ENT/GYN SURGERYUH0.005.520.000.001.13
05B - GENSURG/TRAN/URO/PLAUH0.000.000.000.000.00
06A - MED/PULM/ID/CRITCAREUH8.750.000.000.002.67
06B - GENERAL MED/SURGUH3.280.0017.390.005.06
06E - BURN ICUUH0.000.000.006.371.35
06H - MEDICAL ICUUH0.002.731.341.441.34
06I - MEDICAL ICUUH1.232.891.281.491.69
06K - MED/SURGUH3.393.800.003.122.73
07A - ORTHOPEDICSUH2.310.000.000.000.65
08E - SURGICAL ICUUH1.630.004.980.001.69
08F - CARDIOPULMONARY ICUUH0.001.731.552.941.70
08G - CARDIOVASCULAR MED/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH3.820.000.000.001.12
09F - NEUROSCIENCES ICUUH6.531.453.051.653.31
09G - NEUROSCIENCES M/SUH9.136.214.520.004.77
10E - ONCOLOGYUH3.130.000.000.001.04
10G - MEDICINE UH6.370.000.006.133.32
10H - BONE MARROW TRP UNITUH25.640.000.000.004.57
11G - PEDS HEM/ONCUH0.000.000.000.000.00
12E - PEDIATRICS GENERALUH0.000.000.000.000.00
12F - PEDIATRIC ICUUH0.000.000.000.000.00
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 CCCC0.002.825.750.002.23
6 - 6 MED/SURG/ORTHO CCCC0.0015.540.000.003.28
IC - ICU CCCC0.000.000.000.000.00
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