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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
6thFloor - 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 Q2021_3 and Q2022_2

Unit NameCampusQ2021_3Q2021_4Q2022_1Q2022_2Total
02N - REHABILITATIONUH0.440.000.000.000.11
04B - PSYCHIATRYUH0.600.000.000.000.17
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 ICUUH0.000.000.000.000.00
06I - MEDICAL ICUUH0.000.000.000.000.00
06K - MED/SURGUH0.000.000.000.710.18
07A - ORTHOPEDICSUH0.000.470.000.470.23
07U - SECURED UNITUH0.000.00
08E - SURGICAL ICUUH0.000.000.000.000.00
08F - CARDIOPULMONARY ICUUH0.000.000.000.000.00
08G - CARDIOVASCULAR MED/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH0.000.000.000.000.00
09G - NEUROSCIENCES M/SUH1.190.000.000.590.45
10E - ONCOLOGYUH0.000.000.000.000.00
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH0.000.000.000.000.00
11E - PEDIATRIC SURGERYUH0.000.000.000.000.00
11G - PEDS HEM/ONCUH0.000.001.100.000.27
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 CCCC0.000.000.000.000.00
4E - 4 EAST PMR CCCC1.711.71
4N - 4 NORTH MED/SURG CCCC0.910.000.000.000.25
4W - 4 WEST MED/SURG CCCC0.000.000.000.000.00
5W - 5 WEST PSYCHIATRY CCCC0.000.000.000.690.14
6thFloor - 6 MED/SURG/ORTHO CCCC0.000.000.000.000.00
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 Q2021_3 and Q2022_2

Unit NameCampusQ2021_3Q2021_4Q2022_1Q2022_2Total
02N - REHABILITATIONUH1.790.000.000.000.60
05A - GEN/ENT/GYN SURGERYUH0.000.002.000.000.50
05B - GENSURG/TRAN/URO/PLAUH0.000.000.001.630.45
06A - MED/PULM/ID/CRITCAREUH0.000.000.000.000.00
06B - GENERAL MED/SURGUH1.420.002.000.000.82
06E - BURN ICUUH0.007.430.000.001.83
06H - MEDICAL ICUUH0.000.880.000.000.25
06I - MEDICAL ICUUH0.001.160.000.000.29
06K - MED/SURGUH0.000.000.000.000.00
07A - ORTHOPEDICSUH0.000.000.000.000.00
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH1.550.000.000.000.42
08F - CARDIOPULMONARY ICUUH0.000.000.000.000.00
08G - CARDIOVASCULAR MED/SURGUH0.000.002.390.000.52
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH0.000.000.000.000.00
09G - NEUROSCIENCES M/SUH0.002.420.000.000.54
10E - ONCOLOGYUH0.610.660.662.120.98
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH2.048.322.140.003.15
11E - PEDIATRIC SURGERYUH0.000.000.003.311.26
11G - PEDS HEM/ONCUH0.000.000.000.000.00
12E - PEDIATRICS GENERALUH0.000.000.000.000.00
12F - PEDIATRIC ICUUH5.210.000.000.001.07
3W - 3 WEST MEDICAL CCCC0.000.000.000.000.00
4E - 4 EAST PMR CCCC0.000.000.000.00
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
6thFloor - 6 MED/SURG/ORTHO CCCC0.001.730.000.000.62
IC - ICU CCCC0.001.460.000.000.47

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 NameCampusQ2021_3Q2021_4Q2022_1Q2022_2Total
02N - REHABILITATIONUH11.9014.180.0011.768.85
05A - GEN/ENT/GYN SURGERYUH0.000.003.850.000.86
05B - GENSURG/TRAN/URO/PLAUH2.860.003.440.001.68
06A - MED/PULM/ID/CRITCAREUH0.005.210.000.001.13
06B - GENERAL MED/SURGUH0.000.000.000.000.00
06E - BURN ICUUH0.000.000.006.901.36
06H - MEDICAL ICUUH2.533.880.001.632.11
06I - MEDICAL ICUUH1.234.081.360.001.75
06K - MED/SURGUH0.003.650.000.001.06
07A - ORTHOPEDICSUH4.870.000.002.602.13
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH1.463.170.000.001.24
08F - CARDIOPULMONARY ICUUH1.370.004.400.001.35
08G - CARDIOVASCULAR MED/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.008.620.000.002.28
09F - NEUROSCIENCES ICUUH1.974.632.032.022.59
09G - NEUROSCIENCES M/SUH5.100.000.000.001.21
10E - ONCOLOGYUH0.004.420.000.000.88
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH12.660.000.000.004.83
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 ICUUH0.000.000.007.252.01
3W - 3 WEST MEDICAL CCCC0.000.000.000.000.00
4E - 4 EAST PMR CCCC0.000.000.000.00
4N - 4 NORTH MED/SURG CCCC2.930.000.000.000.76
4W - 4 WEST MED/SURG CCCC10.100.000.000.001.51
6thFloor - 6 MED/SURG/ORTHO CCCC5.522.313.600.002.86
IC - ICU CCCC2.061.850.000.001.00
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