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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 Q2020_3 and Q2021_2

Unit NameCampusQ2020_3Q2020_4Q2021_1Q2021_2Total
02N - REHABILITATIONUH0.000.000.450.000.11
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/SURGUH0.000.000.500.490.24
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/SURGUH0.820.000.000.000.19
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/SURGUH0.000.640.000.000.16
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH0.820.000.000.000.21
09G - NEUROSCIENCES M/SUH0.000.630.620.000.31
10E - ONCOLOGYUH0.000.000.000.000.00
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH0.000.000.001.900.47
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 CCCC0.000.000.000.000.00
3W - 3 WEST MEDICAL CCCC0.000.480.000.000.14
4E - 4 EAST PMR CCCC0.000.000.001.020.23
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 CCCC0.000.450.420.000.21
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_3 and Q2021_2

Unit NameCampusQ2020_3Q2020_4Q2021_1Q2021_2Total
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 ICUUH2.180.000.000.970.78
06I - MEDICAL ICUUH0.001.061.030.000.56
06K - MED/SURGUH0.000.000.000.000.00
07A - ORTHOPEDICSUH1.980.000.000.000.56
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH0.000.000.000.000.00
08F - CARDIOPULMONARY ICUUH1.180.000.000.000.30
08G - CARDIOVASCULAR MED/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.001.500.000.000.40
09F - NEUROSCIENCES ICUUH0.002.531.160.000.98
09G - NEUROSCIENCES M/SUH0.000.001.920.000.60
10E - ONCOLOGYUH0.741.440.001.390.89
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH0.002.392.150.001.19
11E - PEDIATRIC SURGERYUH0.000.000.000.000.00
11G - PEDS HEM/ONCUH0.000.000.000.000.00
12E - PEDIATRICS GENERALUH0.000.007.350.002.56
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 CCCC2.896.020.000.002.59
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 CCCC0.000.000.000.000.00
IC - ICU CCCC2.170.000.000.000.51

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_3 and Q2021_2

Unit NameCampusQ2020_3Q2020_4Q2021_1Q2021_2Total
02N - REHABILITATIONUH0.006.710.000.002.30
05A - GEN/ENT/GYN SURGERYUH0.000.000.000.000.00
05B - GENSURG/TRAN/URO/PLAUH0.005.240.000.001.45
06A - MED/PULM/ID/CRITCAREUH3.333.683.020.002.65
06B - GENERAL MED/SURGUH0.002.600.000.000.86
06E - BURN ICUUH11.054.3314.4910.369.85
06H - MEDICAL ICUUH1.181.084.432.292.25
06I - MEDICAL ICUUH0.001.131.090.000.60
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 ICUUH0.001.420.003.111.10
08F - CARDIOPULMONARY ICUUH2.893.831.350.002.08
08G - CARDIOVASCULAR MED/SURGUH0.000.005.090.001.81
09E - NEUROSCIENCES INTERMEDUH6.643.411.614.714.03
09F - NEUROSCIENCES ICUUH3.231.421.355.632.70
09G - NEUROSCIENCES M/SUH7.190.003.616.374.04
10E - ONCOLOGYUH0.000.000.000.000.00
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH0.000.0016.3912.669.22
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 ICUUH0.000.009.010.002.17
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 CCCC0.000.000.000.000.00
4W - 4 WEST MED/SURG CCCC0.000.000.000.000.00
6thFloor - 6 MED/SURG/ORTHO CCCC0.000.000.007.751.80
IC - ICU CCCC2.041.550.000.000.95
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