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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 Q2022_1 and Q2022_4

Unit NameCampusQ2022_1Q2022_2Q2022_3Q2022_4Total
02N - REHABILITATIONUH0.000.000.000.000.00
04B - PSYCHIATRYUH0.000.000.000.000.00
05A - GEN/ENT/GYN SURGERYUH0.000.000.000.000.00
05B - GENSURG/TRAN/URO/PLAUH0.000.000.520.450.26
06A - MED/PULM/ID/CRITCAREUH0.000.000.000.000.00
06B - GENERAL MED/SURGUH0.000.000.530.000.14
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/SURGUH0.000.710.000.000.18
07A - ORTHOPEDICSUH0.000.470.000.000.12
07U - SECURED UNITUH0.00
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 INTERMEDUH0.000.000.001.130.30
09F - NEUROSCIENCES ICUUH0.000.000.930.000.23
09G - NEUROSCIENCES M/SUH0.000.590.000.000.15
10E - ONCOLOGYUH0.000.000.410.000.10
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/ONCUH1.100.000.000.000.27
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 CCCC0.00
4N - 4 NORTH MED/SURG CCCC0.000.000.000.000.00
4W - 4 WEST MED/SURG CCCC0.000.000.580.000.15
5W - 5 WEST PSYCHIATRY CCCC0.000.690.640.000.31
6thFloor - 6 MED/SURG/ORTHO CCCC0.000.000.410.000.11
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 Q2022_1 and Q2022_4

Unit NameCampusQ2022_1Q2022_2Q2022_3Q2022_4Total
02N - REHABILITATIONUH0.000.000.000.000.00
05A - GEN/ENT/GYN SURGERYUH2.000.000.000.000.47
05B - GENSURG/TRAN/URO/PLAUH0.001.630.000.000.42
06A - MED/PULM/ID/CRITCAREUH0.000.000.002.740.81
06B - GENERAL MED/SURGUH2.000.000.000.000.44
06E - BURN ICUUH0.000.000.003.450.88
06H - MEDICAL ICUUH0.000.001.230.000.28
06I - MEDICAL ICUUH0.000.001.150.000.28
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 ICUUH0.000.000.000.000.00
08F - CARDIOPULMONARY ICUUH0.000.000.000.000.00
08G - CARDIOVASCULAR MED/SURGUH2.390.000.000.000.55
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH0.000.001.370.000.36
09G - NEUROSCIENCES M/SUH0.000.000.001.940.53
10E - ONCOLOGYUH0.662.120.001.200.99
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH2.140.001.977.092.68
11E - PEDIATRIC SURGERYUH0.003.310.000.001.28
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 CCCC0.000.00
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 CCCC0.000.000.002.030.67
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 Q2022_1 and Q2022_4

Unit NameCampusQ2022_1Q2022_2Q2022_3Q2022_4Total
02N - REHABILITATIONUH0.0011.760.000.002.22
05A - GEN/ENT/GYN SURGERYUH3.850.000.000.000.88
05B - GENSURG/TRAN/URO/PLAUH3.440.000.002.511.59
06A - MED/PULM/ID/CRITCAREUH0.000.000.000.000.00
06B - GENERAL MED/SURGUH0.000.000.000.000.00
06E - BURN ICUUH0.006.900.007.754.17
06H - MEDICAL ICUUH0.001.630.000.000.39
06I - MEDICAL ICUUH1.360.000.002.601.08
06K - MED/SURGUH0.000.000.004.931.17
07A - ORTHOPEDICSUH0.002.600.000.000.72
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH0.000.004.202.661.95
08F - CARDIOPULMONARY ICUUH4.400.002.350.001.57
08G - CARDIOVASCULAR MED/SURGUH0.000.007.520.002.47
09E - NEUROSCIENCES INTERMEDUH0.000.004.500.001.20
09F - NEUROSCIENCES ICUUH2.032.020.000.000.99
09G - NEUROSCIENCES M/SUH0.000.004.390.001.14
10E - ONCOLOGYUH0.000.000.003.040.75
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/ONCUH0.000.000.000.000.00
12E - PEDIATRICS GENERALUH0.000.000.000.000.00
12F - PEDIATRIC ICUUH0.007.250.000.002.14
3W - 3 WEST MEDICAL CCCC0.000.005.410.001.21
4E - 4 EAST PMR CCCC0.000.00
4N - 4 NORTH MED/SURG CCCC0.000.000.000.000.00
4W - 4 WEST MED/SURG CCCC0.000.004.814.152.41
6thFloor - 6 MED/SURG/ORTHO CCCC3.600.000.000.000.81
IC - ICU CCCC0.000.000.000.000.00
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