RD 14 Nursing Sensitive Quality Indicators Maintenance of ... · RD 14 Nursing Sensitive Quality Indicators Maintenance of Skin Integrity Massachusetts General Hospital (MGH) participated

RD 14 Nursing Sensitive Quality Indicators

Maintenance of Skin Integrity

Massachusetts General Hospital (MGH) participated in the KCI/Novation National

Prevalence and Incidence (P&I) study from 2003 through 2006. The survey is conducted annually

and involves data collection and submission for 31 patient care units. The results for these years

consistently demonstrated that the prevalence and incidence rates for pressure ulcers at MGH were

below national benchmarks.

2003 2004 2005 2006KCI/Novation* 15% 16% 16% 15%

MGH 11% 14% 14% 10%

2003 2004 2005 2006KCI/Novation* 7% 7% 8% 7%

MGH 3% 4% 3% 3%

# Participating Facilities 232 240 246 260

* Facilities with 500+ beds

KCI/Novation Prevalence Study (Pre-existing and Hospital-Acquired)

KCI/Novation Incidence Study (Hospital Acquired)

The data submitted in 2006 for each unit, the resulting rates for pressure ulcer prevalence

and incidence, and the benchmarks for that year are provided as attachment RD.14.a.

In late 2006, the Massachusetts Patients First Initiative (attachment RD 14.b) selected

Pressure Ulcer Incidence as a quality indicator that would be monitored and reported for all

hospitals in the state. The National Quality Forum (NQF) endorsed methodology was selected for

the study, which differed significantly from the KCI/Novation data collection. In March 2007, a

decision was made to no longer participate in the KCI/Novation study and data was collected for

the first time using the NQF methodology. The Patients First Initiative provided participating

hospitals with their rates for hospital acquired pressure ulcers and state-wide benchmarks, however

discussions with facilities throughout the state indicated problems adapting to the NQF data

collection requirements and resulting concerns regarding data integrity. Hospitals were provided

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with additional guidance and education regarding data collection. At MGH, Clinical Nurse

Specialists conducted two additional surveys in an effort to assure consistent data collection for all

patients. The Pressure Ulcer survey was repeated on September 27, 2007. Attachment RD.14.c

includes the unit level data that was submitted to the Patients First Initiative in October 2007. The

rates by unit type for the September 2007 study and the most recent National Database of Nursing

Quality Indicators (NDNQI) benchmarks (i.e. April-June 2007) are as follows:

Pressure Ulcer Study (September 2007) Critical Care Medical Surgical Med/SurgHospital Acquired Ulcers 7 5 5 2Patients Surveyed 67 248 206 91MGH Rate 10.45% 2.02% 2.43% 2.20%

NDNQI (500+ Beds Apr-Jun 07) 10.42% 4.10% 3.10% 2.57%

The rates for Hospital Acquired Pressure Ulcers for all hospitals in Massachusetts will be

made available to the public by the end of 2007.

Prior to 2007, the decision to continue with the KCI/Novation Pressure Ulcer study was

based primarily on the value of the trended data over time. The findings that indicated favorable

performance and concern regarding the considerable workload involved the data collection helped

to reinforce the decision. The change to the NQF methodology has raised this issue again, since the

data could easily be adapted for NDNQI data submission. The decision regarding submitting NQF

data for pressure ulcer prevalence to NDNQI, along with other issues related to NDNQI

participation, are planned topics to be addressed by the Nursing Executive Operations group in late

Fall 2007. Performance improvement activities related to the prevention of hospital acquired

pressure ulcers are included in OOD 20.

Nursing Care Hours Provided Per Patient Day

The MGH Department of Nursing submits data for nursing care hours provided per patient

day (NHPPD) to the NDNQI. This participation provides a five-year history of performance with

comparative benchmarks for hospitals of comparable size (i.e. greater than 500 beds) for 30

inpatient units. Attachment RD14.d includes data from the most recent NDNQI quarterly report

containing the last 8 quarters of performance data for Total Nursing Hours Per Patient day and RN

Hours Per Patient Day.

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MGH’s performance in these areas is favorable when compared to NDNQI benchmarks.

The NDNQI model of unit groupings has provided the benchmarks by unit type, which has

enhanced our unit-level analysis, as described in OOD 20.

In addition to the NDNQI, MGH submits data for NHPPD to the Massachusetts Patients

First Initiative, which provides a state-wide benchmark, and nursing care hours are submitted to the

QuadraMed® company as a component of Hours Per Workload Index (HPWI), an indicator that

includes a measure of staffing in a ratio with census and acuity (Force 4.3; Force 7.6; OOD 15).

Nursing Staff Satisfaction

MGH Patient Care Services evaluates Staff Nurse satisfaction every eighteen months using

the Staff Perceptions of the Professional Practice Environment Survey (SPPPE). The specific tools

used in the survey are included as OOD 16.a and 16.b. A thorough description of the survey, the

processes involved, and findings for the 2006 survey are depicted in Force 1.8.

At this time, benchmarking data is not available for this internally developed survey,

however, a trend of data using this tool is available from 1999 through 2006. Four years of trend

data is included as RD 6.

Patient Injury Rates (Falls Occurrence)

The MGH Department of Nursing has submitted data for patient falls, including falls that

result in injury, to NDNQI for the past five years. As with NHPPD, data is submitted for 30

inpatient units and reports provide comparative benchmarks for hospitals with greater than 500

beds. Attachment RD 14.e includes data from the most recent NDNQI quarterly report containing

the last 8 quarters of performance data for Fall Rates and Fall with Injury Rates.

The data for MGH’s performance is fairly consistent and indicates some areas of favorable

performance and some areas presenting opportunities for improvement. Fall rates for Adult Critical

Units are usually favorable to the NDNQI mean and rates for Adult Surgical Units are often very

close to the benchmarks. Fall rates for Adult Medical Critical Care Units and Adult Medical/

Surgical Units are frequently unfavorable compared to NDNQI benchmarks. Considering the Fall

with Injury Rates for these areas, however, indicates that MGH performance for all four unit types

are favorable to benchmark. This issue has been discussed in several forums. The quality initiative

of “keeping patients safe”, i.e. preventing falls, also coincides with other initiatives such as restraint

reduction and the ongoing commitment to patient’s rights and independence. In addition, some of

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the MGH efforts around fall prevention are actually directed toward preventing injury in case a fall

occurs, such as using floor mats, hip protectors and renting “low” beds. This may account for the

seeming discrepancy when comparing the findings for the two indicators.

The NDNQI model of unit groupings has provided the benchmarks by unit type, which has

enhanced our unit-level analysis. This enhancement and performance improvement activities related

to fall prevention are described in OOD 20.

Patient Satisfaction

MGH has an on-going program to evaluate patient satisfaction. From 2001 through 2006,

the hospital contracted with Press Ganey for patient satisfaction surveys. A description of the

survey tool, the processes involved, and the quarterly hospital level reports for calendar years 2004

through 2006 are included in RD 5. Attachment RD 14.f includes a sample section of the unit-level

report for October – December 2006 for a group of patient care units, and demonstrating the

findings for the four nursing sensitive indicators of Overall Care, Nursing Care, Pain Management,

and Patient Education. Unit level reports for calendar years 2004 through 2006 are also included in

RD 5.

In these surveys, MGH patients expressed loyalty to the hospital and a high likelihood of

recommending the hospital to others, moreover patients rated their doctors and nurses highly

(compared to other 600+ bed hospitals). At the same time the surveys indicated opportunities for

improvement in areas such as satisfaction with meals, response to calls, rooms and waiting times for

tests and treatments. Performance improvement efforts related to these issues are discussed in RD

5.

Starting in January 2007, MGH began using the Consumer Assessment of Healthcare

Providers and Systems (CAHPS) tool, as required for acute care hospitals for 2008 by the Centers

for Medicare and Medicaid (CMS). It is the first national, standardized survey of adult hospital

patients. Results from this survey, with comparative benchmarks, will be publicly reported

beginning March 2008. MGH has contracted with Quality Data Management (QDM) to administer

the survey and provide ongoing reports. An internal hospital report with three quarters of data for

2007 is included as attachment RD 14.g. As this program is evolving throughout 2007, national

benchmarks are not yet available for comparison. During this transitional period MGH has elected

to use the results from the HCAHPS 2006 pilot of hospitals + 10% as a target for performance until

national means are available. It should be noted that the findings for the two different surveys vary

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significantly (i.e. percentile rating for Press Ganey and percent of respondents selecting the highest

rating for HCAHPS) and as such, the results for the two cannot be compared.

Skill Mix of Registered Nurses, Licensed Practical Nurses, and Unlicensed Staff

The MGH Department of Nursing has submitted data for skill mix to NDNQI for the past

five years. As with NHPPD, data is submitted for 30 inpatient units and reports provide

comparative benchmarks for hospitals with greater than 500 beds. Attachment RD 14.h. includes

data from the most recent NDNQI quarterly report containing the last 8 quarters of performance

data for Percent of Nursing Hours Supplied by RNs.

When compared to NDNQI benchmarks, MGH’s performance in this area is favorable for

Adult Medical Units, Adult Surgical Units, and Adult Medical/Surgical Units. Findings for Adult

Critical Care Units is usually very close to or slightly below the NDNQI mean. The NDNQI model

of unit groupings, providing benchmarks by unit type, has helped to highlight this particular issue

and has resulted in further analysis to better understand the issue. At MGH, Adult Critical Care

Units are budgeted for a 90% RN mix. Analysis of actual performance has indicated that, for four

of the five units, the issue contributing to the discrepancy in Percent of Nursing Hours Supplied by

RNs is use of unlicensed personnel beyond budget. The high percentage of unlicensed personnel

hours is related to using student nurses as Patient Care Associates, which is a long-term recruitment

strategy frequently used by Nursing Directors. Further discussion of this issue will occur in OOD

20.

5

6

Attachment RD 14.a

Attachment RD 14.a continued

7

8


9


10


11


Attachment RD 14.a.continued

Confidential and Proprietary Information

Disclosure to Unauthorized Recipients is Prohibited

Novation / KCI

National P&I Study

Latest Study Completed

March 2006

Novation /KCI National P&I Study

Acute Summary

March 2006

2006

2005

2004

2003

2002

2001

2000

1999 172,71017,510

163,50122,455

143,44524,026

144,42730,559

154,77931,717

164,95631,969

164,95732,815

154,82633,327

Avg%BreakdownAssessed

Prevalence

83865,455

95246,719

75027,545

86249,026

763910,080

76399,643

867310,049

76189,953

Avg%BreakdownAssessed

Incidence

12

Attachment RD 14.b

Endorsed by the Massachusetts Hospital Association and the Massachusetts Organization of

Nurse Executives in January 2005, the Patients First initiative is a quality and safety initiative to

create a work environment in hospitals that supports caregivers and promotes patient safety; help

assure effective staffing; advance best practices in patient care; and involve both patients and the

public in improving that care. All hospitals in the commonwealth adopted the voluntary initiative

by signing a Patients First pledge that committed hospital leaders to specific actions that advance

patient safety and to carry them out in a way that allows patients, caregivers and the public to be

informed and involved.

Massachusetts Hospitals have agreed too participate in the five-part Patients First Agenda

by:

• Demonstrating a commitment to providing nurse staffing that meets patient needs

• Promoting a safe and supportive work environment, with safety and quality as top

priorities

• Providing the public with hospital performance measures for informed decisions about

care

• Building a plentiful and committed workforce

• Educating the public about safe care and creating partnerships to promote access to safe,

high-quality care

To demonstrate the commitment to providing adequate nurse staffing, all hospitals have

made unit-based staffing plans available to the public on the Patients First website

(patientsfirstma.org). Staffing plan data are provided by unit, role group and shift and Worked

Hours Per Patient Day (WHPPD) are calculated based on the number of shifts. On an annual basis,

hospitals provide actual staffing data and WHPPD, which is also posted for the public.

To provide the public with hospital performance measures, all hospitals have agreed to

submit data for fall rates, falls resulting in injury rates, and pressure ulcer rates. Data for these

outcome measures will also be made available to the public on the website by the end of 2007.

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Attachment RD 14.c

MGH Data for September 2007 Pressure Ulcer Survey

Unit Census # Surveyed# of patients with ulcers

Hospital Acquired

Numerator - # Pts. With Hosp. Aquired Stage II

or Greater

Denominator - All Patients

Assessed > 17 yrs

September FY'07 Rate

BIG 7 18 15 0 0 0 15 0.0%BIG 9 16 16 2 2 2 16 12.5%BIG 11 25 20 1 0 0 20 0.0%BIG 13 18 17 4 2 1 17 5.9%BIG 14 25 25 3 1 1 25 4.0%Blk 6 16 15 1 0 0 15 0.0%Blk 7 MICU 18 17 7 3 2 17 11.8%Blk 8 CSICU 14 12 1 1 1 12 8.3%Blk 11 20 15 0 0 0 15 0.0%Blk 12 14 13 0 0 0 13 0.0%Ell 6 33 30 3 0 0 30 0.0%Ell 7 30 25 5 2 2 25 8.0%Ell 8 23 23 0 0 0 23 0.0%Ell 9 CICU 14 9 2 1 1 9 11.1%Ell 10 36 36 2 1 1 36 2.8%Ell 11 35 34 2 0 0 34 0.0%Ell 12 33 30 0 0 0 30 0.0%Ell 14 29 21 0 0 0 21 0.0%Ell 16 29 28 2 1 1 28 3.6%Ell 19 28 23 3 1 0 23 0.0%PH 20 20 17 2 1 0 17 0.0%PH 21 20 17 3 2 2 17 11.8%PH 22 19 17 1 1 0 17 0.0%SICU 16 16 5 5 3 16 18.8%Wht 6 28 14 1 1 0 14 0.0%Wht 7 26 25 2 1 1 25 4.0%Wht 8 25 16 1 0 0 16 0.0%Wht 9 24 21 3 3 1 21 4.8%Wht 10 20 20 0 0 0 20 0.0%Wht 11 24 18 3 0 0 18 0.0%Wht 12 24 22 1 0 0 22 0.0%

720 627 60 29 19 627 3.0%

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Attachment RD 14.d

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg

Blake 12 22.64 23.36 23.90 25.44 23.17 23.02 22.54 22.44 23.31Cardiac SICU 30.03 24.88 22.72 24.44 26.82 26.12 25.60 27.55 26.02CCU 20.00 21.47 18.43 18.34 20.69 18.37 18.34 20.83 19.56MICU 21.23 21.23 20.33 20.71 22.29 19.84 22.54 21.31 21.18SICU 26.39 25.88 25.74 28.50 26.77 24.34 25.92 27.93 26.43Hospital Adult Critical Care Average

24.06 23.36 22.22 23.49 23.95 22.34 22.98 24.01 23.30

Mean 17.68 17.83 17.70 17.80 18.02 17.87 17.93 18.30 17.89Upper Quartile Cut Point 19.30 19.42 19.48 19.26 19.29 19.09 19.31 19.73 19.36Lower Quartile Cut Point 15.54 15.71 15.53 15.62 16.11 15.87 15.88 15.96 15.78# of Reporting Units 438 447 445 444 456 469 498 476 459

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg

Bigelow 11 8.34 8.39 7.66 7.75 8.61 8.68 9.69 9.28 8.55Ellison 10 11.41 11.59 10.60 10.50 10.47 10.18 10.36 10.83 10.74Ellison 11 10.48 10.16 9.28 9.64 10.48 10.50 9.78 10.25 10.07Ellison 14 11.49 11.86 11.25 12.00 12.15 12.62 13.01 13.25 12.20Ellison 16 8.74 8.85 8.54 9.12 8.83 8.88 9.26 9.49 8.96Phillips House 20 8.59 8.29 8.43 8.64 9.40 9.07 9.35 8.90 8.83Phillips House 21 9.16 9.03 9.55 10.17 10.18 10.45 10.41 10.78 9.97White 10 9.69 10.57 9.35 9.85 9.64 11.32 10.81 10.26 10.19White 11 9.54 9.27 9.30 9.74 9.62 9.26 9.94 9.77 9.55White 8 8.52 9.14 8.80 9.21 9.71 9.71 9.91 10.05 9.38White 9 7.47 7.91 7.50 8.84 9.07 8.96 8.76 8.75 8.41Hospital Adult Medical Average 9.40 9.55 9.12 9.59 9.83 9.97 10.12 10.15 9.71


National Comparative Information^ - Bedsize >= 500

Table 1 Adult MedicalTotal Nursing Hours Per Patient Day

Massachusetts General Hospital


Adult Medical

Table 1 Adult Critical Care

Total Nursing Hours Per Patient Day


Adult Critical Care

15

Attachment RD 14.d continued

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg

Bigelow 13 12.97 15.64 14.45 15.60 14.00 14.48 14.26 14.25 14.46Bigelow 14 9.47 9.54 9.38 10.83 9.68 10.33 10.20 10.28 9.97Bigelow 7 9.63 11.11 10.41 11.70 10.06 11.14 10.50 10.95 10.69Blake 6 14.44 14.60 12.31 13.88 12.00 12.53 12.06 13.34 13.15Ellison 6 8.28 8.96 8.92 9.23 8.36 9.52 9.72 10.20 9.15Ellison 7 10.81 11.59 10.91 11.62 11.60 12.01 11.62 10.85 11.38Ellison 8 13.09 11.96 10.68 10.88 10.92 11.74 10.70 11.15 11.39Phillips House 22 8.36 8.90 8.63 9.13 8.23 9.18 9.02 9.33 8.85White 6 9.10 9.31 8.53 8.77 9.39 9.53 8.77 9.05 9.06White 7 9.36 9.84 9.22 9.38 9.86 9.89 9.83 9.66 9.63Hospital Adult Surgical Average 10.55 11.14 10.34 11.10 10.41 11.04 10.67 10.91 10.77


3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg

Bigelow 9 12.42 12.44 12.24 13.21 11.54 12.29 12.17 12.39 12.34Ellison 12 8.80 10.66 9.88 10.75 10.38 9.98 9.30 10.20 9.99Ellison 19 9.46 10.56 10.51 10.27 10.85 9.83 10.62 10.45 10.32White 12 9.72 9.73 9.79 10.33 9.84 10.88 10.72 10.60 10.20Hospital Adult Med-Surg Combined Average

10.10 10.85 10.60 11.14 10.65 10.74 10.70 10.91 10.71


Total Nursing Hours Per Patient DayMassachusetts General Hospital

Adult Med-Surg Combined



Adult Surgical


Table 1 Adult Med-Surg Combined

Table 1 Adult SurgicalTotal Nursing Hours Per Patient Day

16



3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg


21.08 20.84 19.55 20.53 20.54 19.65 20.22 20.87 20.41


3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg




Table 2 Adult MedicalRN Hours Per Patient Day



Adult Medical

RN Hours Per Patient Day


Adult Critical Care

17


Table 2 Adult Surgical

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg



3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg


8.32 8.99 8.77 9.20 8.55 8.96 8.98 9.11 8.86

Mean 5.31 5.54 5.50 5.59 5.69 5.68 5.57 5.72 5.57Upper Quartile Cut Point 6.00 6.35 6.29 6.42 6.39 6.42 6.27 6.44 6.32Lower Quartile Cut Point 4.27 4.46 4.40 4.50 4.64 4.66 4.63 4.73 4.54

RN Hours Per Patient DayMassachusetts General Hospital




Adult Surgical


Table 2 Adult Med-Surg Combined

RN Hours Per Patient Day

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Attachment RD 14.e

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg


0.98 1.59 0.76 4.05 1.11 0.43 2.35 1.49 1.60


3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg




Table 11 Adult MedicalTotal Falls Per 1,000 Patient DaysMassachusetts General Hospital

Adult Medical



Total Falls Per 1,000 Patient Days


Adult Critical Care

19

Attachment RD 14.e continued

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg



3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg


5.38 4.89 5.49 4.12 5.83 6.25 4.12 4.03 5.01



Table 11 Adult Med-Surg CombinedTotal Falls Per 1,000 Patient DaysMassachusetts General Hospital




Total Falls Per 1,000 Patient Days


Adult Surgical

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3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg


0.00 0.32 0.13 0.66 0.14 0.00 0.16 0.17 0.20


3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg




Table 12 Adult MedicalInjury Falls Per 1,000 Patient DaysMassachusetts General Hospital

Adult Medical



Injury Falls Per 1,000 Patient Days


Adult Critical Care

21


3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg



3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 Avg


0.74 0.56 0.36 0.66 0.43 0.50 0.00 0.52 0.47



Table 12 Adult Med-Surg CombinedInjury Falls Per 1,000 Patient DaysMassachusetts General Hospital




Injury Falls Per 1,000 Patient Days


Adult Surgical

22

Attachment RD 14.f

23

Attachment RD 14.f continued

24

Attachment RD 14.f continued

25

Attachment RD 14.g

26

Attachment RD 14.g continued

Please note: The scores on this dashboard have been rounded to the nearest whole number 1 Preliminary data from Quality Data Management (QDM); percent surveys completed; unshaded if less than 50% complete 2 Agency for Healthcare Research and Quality

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Attachment RD 14.h

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07

Avg

Blake 12 80.81 79.72 79.20 80.71 78.58 79.38 79.40 80.13Cardiac SICU 89.49 89.63 89.70 88.78 88.69 88.37 88.88 87.63CCU 92.44 94.59 94.26 92.92 89.42 94.41 94.52 92.77MICU 86.34 92.76 90.97 88.57 83.97 88.80 88.81 86.65SICU 88.32 89.70 87.78 87.54 87.67 90.07 89.21 87.65Hospital Adult Critical Care Avera

79.7488.9093.1688.3688.49

ge87.48 89.28 88.38 87.70 85.67 88.21 88.16 86.96

Mean 88.44 89.16 89.46 88.74 88.29 88.93 88.94 88.71Upper Quartile Cut Point 93.13 94.53 94.72 93.30 92.56 93.37 93.48 93.72Lower Quartile Cut Point 84.33 84.47 84.53 84.43 83.97 84.49 84.40 83.79# of Reporting Units 445 453 446 447 458 473 502 484

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07

87.73

88.8393.6084.30464

Avg

Bigelow 11 98.85 98.87 99.24 98.65 99.17 99.52 99.85 99.53Ellison 10 83.32 85.00 83.67 84.52 84.41 83.73 84.46 84.82Ellison 11 82.74 82.76 84.29 82.32 80.14 86.57 87.12 85.20Ellison 14 84.37 88.71 88.25 87.41 85.79 85.91 86.73 84.87Ellison 16 81.93 81.19 84.55 83.16 83.02 84.01 83.60 81.53Phillips House 20 78.65 78.46 75.82 76.60 78.55 75.72 75.96 76.66Phillips House 21 78.78 76.99 74.65 74.53 78.99 79.76 79.89 80.03White 10 79.45 82.72 86.73 81.75 81.20 79.32 78.86 79.64White 11 83.20 84.43 85.45 86.72 83.67 86.39 85.94 83.98White 8 80.22 80.45 82.98 80.78 81.16 80.57 80.50 80.46White 9 83.16 78.20 76.62 78.79 79.62 80.96 81.14 80.01Hospital Adult Medical Avera

99.2184.2483.8986.5082.8777.0577.9581.2184.9780.8979.81

ge 83.15 83.43 83.84 83.20 83.25 83.86 84.00 83.34

Mean 65.76 66.54 67.36 66.21 66.32 66.91 67.54 67.69Upp r Quartile Cut Point 73.02 73.16 73.73 72.86 72.90 73.56 74.10 73.69Low Cut Point 58.69 59.61 60.53 59.43 59.82 60.18 60.90 60.53# of Re 443 464 471 506 497

Nati nal Comparative Information^ - Bedsize >= 500

83.51

66.7973.3859.96458

o

Table 5 Adult MedicalPercent of Total Nursing Hours Supplied By RNs


Adult Medical



Percent of Total Nursing Hours Supplied By RNs


Adult Critical Care

eer Quartile

porting Units 422 426 438

28

29

Attachment RD 14.h continued

073Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q Avg

Bigelow 13 89.39 88.97 87.13 87.44 88.17 89.89 89.89 86.78Bi

88.46gelow 14 80.80 81.13 79.33 80.20 78.77 83.23 81.46 78.75

Bi80.46

gelow 7 80.74 80.76 80.85 83.67 83.48 83.37 82.42 82.80Blake 6 82.76 82.79 82.58 81.37 78.37 80.56 81.02 81.60Ellison 6 79.95 80.14 80.78 81.10 80.56 77.85 79.44 80.73Ellison 7 85.02 85.20 83.69 83.29 82.73 83.52 83.62 83.99Ellison 8 80.81 80.50 80.74 79.16 83.50 81.10 80.00 78.67Phillips House 22 82.20 82.45 79.64 80.36 81.23 82.15 81.42 79.46White 6 82.10 81.45 82.27 80.22 78.34 81.70 81.04 78.96White 7 81.96 82.64 82.21 81.34 80.52 79.92 79.51 80.90Hospital Adult Sur

82.2681.3880.0783.8880.5681.1180.7681.13

gical Average 82.57 82.60 81.92 81.82 81.57 82.33 81.98 81.26

Mean 66.29 67.19 67.64 67.25 67.91 68.15 68.47 68.60Upper Quartile Cut Point 72.37 72.94 73.06 73.02 73.96 73.54 74.40 73.85Lower Quartile Cut Point 59.94 61.21 61.95 61.29 62.14 62.17 62.61 62.16# of Reportin

82.01

67.6973.3961.69

g Units 310 326 328 325 349 356 379 365

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q

342

07 Avg

Bigelow 9 84.10 84.07 84.53 87.40 84.11 84.43 84.27 84.41Ellison 12 81.04 82.14 83.11 81.07 79.79 82.75 82.75 82.87Ellison 19 83.57 83.38 83.53 82.20 81.84 85.23 86.48 87.31White 12 79.95 81.31 79.05 78.15 74.41 81.21 81.78 79.39Hospital Adult Med-Surg Combined Avera

84.6681.9484.1979.41

ge82.17 82.73 82.55 82.20 80.04 83.41 83.82 83.49

Mean 63.60 65.78 66.55 65.73 65.98 66.24 66.49 66.37Upper Quartile Cut Point 70.47 72.69 73.08 72.59 72.84 73.52 74.03 73.17Lower Quartile Cut Point 56.87 58.39 59.82 58.71 59.01 59.06 59.43 59.24# of Reportin

82.55

65.8472.8058.82

g Units 306 306 289 292 291 309 321 310


303

Table 5 Adult Med-Surg CombinedPercent of Total Nursing Hours Supplied By RNs





Percent of Total Nursing Hours Supplied By RNs


Adult Surgical

Documents

RD 14 Nursing Sensitive Quality Indicators Maintenance of ... · RD 14 Nursing Sensitive Quality Indicators Maintenance of Skin Integrity Massachusetts General Hospital (MGH) participated