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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
3W - 3 WEST MEDICAL CCMED/SURGCC
4E - 4 EAST PMR CCSPECIAL UNITCC
4N - 4 NORTH MED/SURG CCMED/SURGCC
4W - 4 WEST 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 Q2020_2 and Q2021_1

Unit NameCampusQ2020_2Q2020_3Q2020_4Q2021_1Total
02N - REHABILITATIONUH0.000.000.000.450.11
04B - PSYCHIATRYUH0.000.000.000.000.00
05A - GEN/ENT/GYN SURGERYUH0.000.000.000.000.00
05B - GENSURG/TRAN/URO/PLAUH0.000.000.000.000.00
06A - MED/PULM/ID/CRITCAREUH0.000.000.000.000.00
06B - GENERAL MED/SURGUH0.000.000.000.500.12
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/SURGUH0.000.820.000.000.20
07A - ORTHOPEDICSUH0.000.000.000.000.00
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH0.000.000.000.000.00
08F - CARDIOPULMONARY ICUUH0.000.000.000.000.00
08G - CARDIOVASCULAR MED/SURGUH0.000.000.640.000.17
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH0.000.820.000.000.22
09G - NEUROSCIENCES M/SUH0.000.000.630.620.32
10E - ONCOLOGYUH0.000.000.000.000.00
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH2.130.000.000.000.49
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 ICUUH0.000.000.000.000.00
2 - 2 POSTPARTUM GYN CCCC0.00
2L - LABOR AND DELIVERY CCCC0.00
3W - 3 WEST MEDICAL CCCC0.000.000.480.000.16
4E - 4 EAST PMR CCCC0.000.000.000.000.00
4N - 4 NORTH MED/SURG CCCC0.000.000.000.000.00
4W - 4 WEST MED/SURG CCCC0.000.000.000.000.00
5W - 5 WEST PSYCHIATRY CCCC0.000.000.000.000.00
6 - 6 MED/SURG/ORTHO CCCC0.000.000.450.420.24
EU - EPILEPSY MONITORING UNIT CCCC0.000.000.000.000.00
IC - ICU CCCC0.000.000.000.000.00

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 Q2020_2 and Q2021_1

Unit NameCampusQ2020_2Q2020_3Q2020_4Q2021_1Total
02N - REHABILITATIONUH0.000.000.000.000.00
05A - GEN/ENT/GYN SURGERYUH0.000.000.000.000.00
05B - GENSURG/TRAN/URO/PLAUH0.000.000.000.000.00
06A - MED/PULM/ID/CRITCAREUH0.000.000.000.000.00
06B - GENERAL MED/SURGUH0.000.000.000.000.00
06E - BURN ICUUH0.000.000.000.000.00
06H - MEDICAL ICUUH0.002.180.000.000.56
06I - MEDICAL ICUUH0.000.001.061.030.58
06K - MED/SURGUH0.000.000.000.000.00
07A - ORTHOPEDICSUH0.001.980.000.000.64
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH0.000.000.000.000.00
08F - CARDIOPULMONARY ICUUH0.001.180.000.000.32
08G - CARDIOVASCULAR MED/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.000.001.500.000.43
09F - NEUROSCIENCES ICUUH0.000.002.531.161.02
09G - NEUROSCIENCES M/SUH0.000.000.001.920.63
10E - ONCOLOGYUH0.000.741.440.000.55
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH0.000.002.392.151.20
11E - PEDIATRIC SURGERYUH0.000.000.000.000.00
11G - PEDS HEM/ONCUH1.960.000.000.000.62
12E - PEDIATRICS GENERALUH0.000.000.007.352.55
12F - PEDIATRIC ICUUH9.430.000.000.002.26
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 CCCC0.002.896.020.002.78
4W - 4 WEST MED/SURG CCCC0.000.000.000.000.00
5W - 5 WEST PSYCHIATRY CCCC0.000.000.000.000.00
6 - 6 MED/SURG/ORTHO CCCC0.000.000.000.000.00
IC - ICU CCCC0.002.170.000.000.52

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 Q2020_2 and Q2021_1

Unit NameCampusQ2020_2Q2020_3Q2020_4Q2021_1Total
02N - REHABILITATIONUH0.000.006.710.002.57
05A - GEN/ENT/GYN SURGERYUH0.000.000.000.000.00
05B - GENSURG/TRAN/URO/PLAUH0.000.005.240.001.58
06A - MED/PULM/ID/CRITCAREUH4.293.333.683.023.52
06B - GENERAL MED/SURGUH0.000.002.600.000.93
06E - BURN ICUUH0.0011.054.3314.498.81
06H - MEDICAL ICUUH0.001.181.084.431.73
06I - MEDICAL ICUUH0.000.001.131.090.61
06K - MED/SURGUH0.000.000.000.000.00
07A - ORTHOPEDICSUH3.760.000.000.000.71
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH3.400.001.420.001.13
08F - CARDIOPULMONARY ICUUH0.002.893.831.352.29
08G - CARDIOVASCULAR MED/SURGUH0.000.000.005.091.99
09E - NEUROSCIENCES INTERMEDUH0.006.643.411.613.08
09F - NEUROSCIENCES ICUUH2.003.231.421.351.95
09G - NEUROSCIENCES M/SUH0.007.190.003.612.79
10E - ONCOLOGYUH0.000.000.000.000.00
10G - MEDICINE UH7.580.000.000.001.62
10H - BONE MARROW TRP UNITUH0.000.000.0016.394.48
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 ICUUH0.000.000.009.012.07
3W - 3 WEST MEDICAL CCCC3.640.000.000.000.89
4E - 4 EAST PMR CCCC0.000.000.000.000.00
4N - 4 NORTH MED/SURG CCCC0.000.000.000.000.00
4W - 4 WEST MED/SURG CCCC0.000.000.000.000.00
6 - 6 MED/SURG/ORTHO CCCC0.000.000.000.000.00
IC - ICU CCCC0.002.041.550.000.97
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