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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 Q2019_2 and Q2020_1

Unit NameCampusQ2019_2Q2019_3Q2019_4Q2020_1Total
02N - REHABILITATIONUH0.440.000.000.000.11
04B - PSYCHIATRYUH0.000.000.000.000.00
05A - GEN/ENT/GYN SURGERYUH0.000.500.000.000.13
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 ICUUH0.000.000.000.790.19
06I - MEDICAL ICUUH0.000.000.000.000.00
06K - MED/SURGUH0.750.000.000.000.19
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/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH0.880.000.000.000.22
09G - NEUROSCIENCES M/SUH0.000.000.000.000.00
10E - ONCOLOGYUH0.000.000.420.000.11
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 GENERALUH0.000.000.610.000.16
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 CCCC0.000.000.000.000.00
4E - 4 EAST PMR CCCC0.001.060.000.000.28
4N - 4 NORTH MED/SURG CCCC0.000.000.000.000.00
5W - 5 WEST PSYCHIATRY CCCC0.000.480.000.000.12
6 - 6 MED/SURG/ORTHO CCCC0.000.000.510.000.14
EU - EPILEPSY MONITORING UNIT CCCC0.000.000.000.000.00
IC - ICU CCCC1.870.000.000.000.42

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 Q2019_2 and Q2020_1

Unit NameCampusQ2019_2Q2019_3Q2019_4Q2020_1Total
02N - REHABILITATIONUH0.000.000.00
05A - GEN/ENT/GYN SURGERYUH0.000.000.00
05B - GENSURG/TRAN/URO/PLAUH3.550.002.24
06A - MED/PULM/ID/CRITCAREUH0.000.000.00
06B - GENERAL MED/SURGUH0.000.000.00
06E - BURN ICUUH0.0012.745.10
06H - MEDICAL ICUUH1.330.000.74
06I - MEDICAL ICUUH0.000.000.00
06K - MED/SURGUH0.005.972.38
07A - ORTHOPEDICSUH0.000.000.00
07U - SECURED UNITUH0.000.000.00
08E - SURGICAL ICUUH0.000.000.00
08F - CARDIOPULMONARY ICUUH0.000.000.00
08G - CARDIOVASCULAR MED/SURGUH0.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.000.000.00
09F - NEUROSCIENCES ICUUH0.000.000.00
09G - NEUROSCIENCES M/SUH3.450.002.00
10E - ONCOLOGYUH0.660.000.43
10G - MEDICINE UH0.003.441.39
10H - BONE MARROW TRP UNITUH2.450.001.50
11E - PEDIATRIC SURGERYUH0.007.633.64
11G - PEDS HEM/ONCUH2.120.001.32
12E - PEDIATRICS GENERALUH0.000.000.00
12F - PEDIATRIC ICUUH0.003.831.80
3W - 3 WEST MEDICAL CCCC0.000.000.00
4E - 4 EAST PMR CCCC0.000.000.00
4N - 4 NORTH MED/SURG CCCC0.000.000.00
5W - 5 WEST PSYCHIATRY CCCC0.000.000.00
6 - 6 MED/SURG/ORTHO CCCC3.794.220.000.002.08
IC - ICU CCCC0.000.000.00

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 Q2019_2 and Q2020_1

Unit NameCampusQ2019_2Q2019_3Q2019_4Q2020_1Total
02N - REHABILITATIONUH11.3615.750.000.008.57
05A - GEN/ENT/GYN SURGERYUH0.000.003.920.001.04
05B - GENSURG/TRAN/URO/PLAUH0.000.000.000.000.00
06A - MED/PULM/ID/CRITCAREUH0.003.660.000.001.10
06B - GENERAL MED/SURGUH0.000.000.000.000.00
06E - BURN ICUUH6.370.0010.7010.996.85
06H - MEDICAL ICUUH1.440.004.823.822.48
06I - MEDICAL ICUUH1.491.350.000.000.74
06K - MED/SURGUH3.123.890.000.002.02
07A - ORTHOPEDICSUH0.003.300.000.000.76
07U - SECURED UNITUH0.0015.150.000.004.90
08E - SURGICAL ICUUH0.004.791.492.502.19
08F - CARDIOPULMONARY ICUUH2.941.630.002.431.67
08G - CARDIOVASCULAR MED/SURGUH0.000.000.006.801.26
09E - NEUROSCIENCES INTERMEDUH0.000.008.930.002.98
09F - NEUROSCIENCES ICUUH1.655.534.790.003.52
09G - NEUROSCIENCES M/SUH0.000.000.000.000.00
10E - ONCOLOGYUH0.000.003.380.001.14
10G - MEDICINE UH6.130.007.630.003.82
10H - BONE MARROW TRP UNITUH0.000.000.000.000.00
11E - PEDIATRIC SURGERYUH0.000.000.0020.004.24
11G - PEDS HEM/ONCUH0.000.000.000.000.00
12E - PEDIATRICS GENERALUH0.000.000.000.000.00
12F - PEDIATRIC ICUUH0.004.930.000.001.60
3W - 3 WEST MEDICAL CCCC0.000.000.006.331.05
4E - 4 EAST PMR CCCC0.000.000.000.000.00
4N - 4 NORTH MED/SURG CCCC0.002.910.000.000.78
6 - 6 MED/SURG/ORTHO CCCC0.000.000.000.000.00
IC - ICU CCCC0.006.580.000.002.23
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