implementation guide 2010

Implementation Guide
for the NQF Endorsed
Nursing-Sensitive Care
Measure Set
2009

Last Updated: Version 2.0

Right to Copy, Reprint, and Use

The Implementation Guide for the NQF Endorsed Nursing-Sensitive Care Performance
Measures (Version 2.0, December 2009) (“Implementation Guide”) is the intellectual
property of the Joint Commission, Oakbrook Terrace, Illinois, (“Joint Commission”), and
may not be copied or reprinted by any party, by any means, including electronic, without
express written permission from the Joint Commission, except as expressly permitted
herein. Subject to and on condition of compliance with the acknowledgement and
updating disclosure requirements described below, the Joint Commission hereby grants
all organizations or individuals the nonexclusive right to copy or reprint the contents of
the Implementation Guide solely for measurement purposes, including incorporation into
patient or client data collection forms or software. However, permission is not hereby
granted any organization or individual to place all or any part of the Implementation
Guide on the Internet for public access, or copy or reprint all or any part of the
Implementation Guide for sale, without express written permission from the Joint
Commission.

No royalty or use fee is required for permitted uses, but required as a condition of the
permission granted are: (1) acknowledgement of the Joint Commission’s ownership,
and (2) disclosure that the Implementation Guide is periodically updated and that the
version being copied or reprinted may not be up-to-date when used.

Example Acknowledgement and Disclosure: The Implementation Guide for the NQF
Endorsed Nursing-Sensitive Care Performance Measures, [Version 2.0,
December,2009] is the intellectual property of and copyrighted by the Joint Commission,
Oakbrook Terrace, Illinois. It is used in this ______________ with the permission of the
Joint Commission.

Copyright© 2010 by the Joint Commission, One Renaissance Boulevard, Oakbrook
Terrace, Illinois 60181.

All rights reserved.
Any other requests for permission to reprint or make copies of all or any part of this
Implementation Guide not granted herein should be addressed to:

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The Joint Commission
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Implementation Guide The Joint Commission, 2009
NSC Measure Set


Table of Contents

Introduction and Background

Using the Implementation Guide

Measure Set List and Descriptors

Section 1 Data Dictionary
Introduction to the Data Dictionary
Data Elements by Measure List
Alphabetical Data Dictionary

Section 2 Measure Information

NSC-1 Death Among Surgical Inpatients with Treatable Serious
Complications
NSC-2 Pressure Ulcer Prevalence (Hospital-Acquired)
NSC-3 Restraint Prevalence
NSC-4 Patient Falls
NSC-5 Falls with Injury
NSC-6 Catheter-Associated Urinary Tract Infections (UTI) for
Intensive Care Unit (ICU) Patients
NSC-7 Central Line Catheter-Associated Blood Stream Infections
for ICU and Neonatal Intensive Care Unit (NICU) Patients
NSC-8 Ventilator-Associated Pneumonia for ICU and NICU Patients
NSC-9 Skill Mix
NSC-10 Nursing Care Hours per Patient Day
NSC-11 Voluntary Turnover
NSC-12 Practice Environment Scale-Nursing Work Index (PES-NWI)

Appendices
A. Glossary of Terms
B. Overview of Measure Information Form and Flowchart Formats
C. Resources
D. Miscellaneous Tables
TABLE 1. International NPUAP-UPUAP Pressure Ulcer Guidelines
TABLE 2. Patient Day Reporting Methods
TABLE 3. Unit Structure Definitions
TABLE 4. ICU Location Definitions
TABLE 5. Nursing Hours Reporting Schedule Example
E. Prevalence Study Methodology
F. Device Related Infection Measure Criteria
G. PES-NWI Nurse Survey

NSC Measure Set


Introduction and Background

Nursing-Sensitive Care Performance Measures

The development of this implementation guide and the subsequent testing of the
requisite measures was done in two phases by The Joint Commission with funding from
the Robert Wood Johnson Foundation (RWJF). The first phase required the integration
of all identified measures from disparate measure developers at the data element level,
the establishment of uniform technical specifications, and the creation of standardized
specifications in an implementation guide. Subsequently, additional funding was
obtained from RWJF for comprehensive testing of the nursing-sensitive care measure
set for reliability, feasibility and impact on quality of care. The following describes the
history of the nursing-sensitive measures and the consequent development of the
implementation guide and completion of measure testing.

The History of the Nursing-Sensitive Care Measures

In January 2004, the National Quality Forum (NQF) identified and endorsed 15 national
voluntary consensus standards1 for nursing-sensitive care including evidence-based
performance measures, a framework for measuring nursing-sensitive care, and related
research recommendations. These performance measures were identified through the
established NQF Consensus Development Process that brings together diverse
healthcare stakeholders.

As with other NQF consensus projects, A Steering Committee representing key
healthcare constituencies – including consumers, providers, purchasers, and research
and quality improvement organizations-was convened to establish the initial approach to
identifying, assessing and recommending the consensus standards. In September 2003
the Committee recommended a set of measures that was forwarded to NQF Members
and the public for comment in accordance with NQF’s Consensus Development
Process (CDP). In September 2003, following the Steering Committee’s selection and
recommendation of measures, a three-member Technical Advisory Panel (TAP) was
also consulted. The TAP’s role was to serve as additional technical review of the
measures, as well as to advise NQF on specific scientific and research issues that
might inform discussions on outstanding questions before the Committee.
1
Voluntary consensus standards are defined as “common and repeated use of rules,
conditions, guidelines or characteristics for products or related processes and
production methods, and related management systems practices; the definition of
terms; classification of components; delineation of procedures; specification of
dimensions, materials, processes, products, systems, services, or practices; test
methods and sampling procedures; or descriptions of fit and measurements of size or
strength.” U.S. Office of Management and Budget, Revised Circular A-119, Federal
Participation in the Development and Use of Voluntary Consensus Standards and in
Conformity Assessment Activities; February 10, 1998.

NSC Measure Set i


This initial measure set complemented and extended existing hospital care measures
with links to nursing care in the NQF National Voluntary Consensus Standards for
Hospital Care: An Initial Performance Measure Set. Most of the endorsed measures are
derived from other national hospital and nursing initiatives (e.g., Centers for Medicare
and Medicaid Services-Quality Improvement Organizations [CMS-QIOs], The Joint
Commission-Core Measures [Specifications Manual for National Implementation of
Hospital Core Measures], the American Nurses Association-National Database of
Nursing Quality Indicators [ANA-NDNQI], Collaborative Alliance for Nursing Outcomes
[CALNOC] database project, VHA Inc.).

The identification of this initial nursing-sensitive measure set by the National Quality
Forum was a significant first step towards national standardized measurement of
nursing resource structures as well as outcomes and processes sensitive to the impact
of nursing care. However, successful implementation of these measures on a national
scale requires the availability of a single source of standardized technical specifications.

The Nursing-Sensitive Care Performance Measures: An Initial Set

The value and benefit of using multiple measures as a set to obtain a robust picture of
performance and quality of care is recognized. Measure sets commonly have a disease
(e.g., diabetes), or condition (e.g., acute myocardial infarction) focus. Generally,
measures are designed to look at structure, processes and outcomes of care related to
these foci. However, the nursing sensitive care measure set represents a unique
approach in assessing quality of care. Nurses provide a critical role in the care of
hospitalized patients. Quantifying the effect that nurses and nursing interventions have
on the quality of care processes, and on patient outcomes, has become increasingly
important to support evidence-based staffing plans, understand the impact of nursing
shortages and optimize care outcomes. This initial measure set was designed to include
patient-centered outcome measures, nurse-centered intervention measures and
system-centered measures. As such, this set provides unique measurement
opportunities and challenges. The measures in the set do not address a single,
common population. Rather, measurement targets include patients, nursing staff and
system factors. Data are derived from multiple sources such as surveys, patient
administrative databases and human resource records. Health care organizations will
need to carefully examine the criteria for each measure “population” and determine
reliable, consistent data collection options. Over time, the collection of data for these
measures will enhance the available evidence and understanding of the relationship
between nursing related system (structural) characteristics and patient care processes
and outcomes at your organization. The use of standardized specifications for these
measures will provide the groundwork for future inter-organizational comparisons as
well as intra-organizational comparisons over time.

NSC Measure Set ii


PHASE 1 Development of the Nursing-Sensitive Care Performance Measure
Implementation Guide: A Collaborative Effort

A Joint Commission proposal to develop an implementation guide with standardized
technical specifications for these measures was accepted for funding by the Robert
Wood Johnson Foundation and the project was implemented in October 2004. The Joint
Commission has gained extensive experience and expertise in the development,
specification, testing and implementation of performance measures over the past 20
years.

This project was based on collaborative efforts among various stakeholders. The major
objectives of developing a Technical Implementation Guide of standardized
specifications included:
1. Development and review of a Technical Implementation Guide for the Nursing-
Sensitive Care Performance Measures.
2. Creation of standardized specifications across the nursing-sensitive care
performance measures.
3. Facilitation of uniform implementation of performance measures by interested
health care organizations.
4. Promotion of national implementation of the nursing-sensitive care measures.
5. Exploration of seamless data collection through the use of the electronic medical
record.
The development of this implementation guide with standardized specifications would
not have been possible without the support and collaboration of the endorsed measure
developers who served as part of a Technical Advisory Panel (TAP) providing advice
and guidance for this project. The guide consolidated individual measure specifications,
presenting them in uniform formats, and provides a centralized data dictionary and
glossary of terms.

Finalizing the Technical Specifications For National Implementation

The Implementation Guide for the NQF Endorsed Nursing-Sensitive Care Performance
Measures was reviewed for utility and feasibility by a random sample of volunteer
hospitals. Pilot site comments were obtained through written survey, focus group
conference calls, and onsite visits. Specifications were also reviewed by several
electronic medical record vendors with acute care (hospital) applications, as well as
performance measurement systems active in the Joint Commission’s ORYX® initiative.
Based on TAP recommendations and pilot site, system and vendor input, the final
revisions were completed in fall, 2005. Therefore, the completed specifications initially
released in February 2006 were based on information from multiple sources including:
the measure developers, the TAP, electronic health record vendors, performance
measurement systems and pilot test sites.

NSC Measure Set iii


PHASE 2 Comprehensive Testing of the Nursing-Sensitive Care Performance
Measures

In January 2007, The Joint Commission received funding from the Robert Wood
Johnson Foundation to test the implementation of the National Quality Forum (NQF)
Endorsed Nursing-Sensitive Care (NSC) Performance Measure Set in a group of
volunteer hospitals. During the 24 month period, in keeping with defined project
activities and timeframes, the project staff:
• Convened a Technical Advisory Panel (TAP)
• Engaged the Joint Commission’s Nursing Advisory Council (NAC)
• Updated the Technical Specifications and Implementation Guide for the NQF
Endorsed Nursing-Sensitive Care Performance Measures
• Recruited and enrolled test sites
• Developed and provided site training
• Developed an electronic data entry and transmission software for the pilot test
• Initiated and completed data collection and transmission
• Supported pilot test sites
• Conducted reliability test visits
• Administered a qualitative survey
• Developed and collected activity logs tracking resources
• Analyzed data and prepared reports

Project staff recruited and selected a stratified random sample of 54 pilot test sites
consistent with the proposed project methodology. Site recruitment was initiated in May
2007 using multiple strategies including posting a notice on the Joint Commission web
site in May 2007 and via a list serve to all Joint Commission accredited organizations.

The Colorado Hospital Association (CHA), the 55th test site, had contacted the Joint
Commission to explore the possibility of member hospitals participating in the test. This
was in response to the Governor of Colorado issuing an Executive Order in March 2007
establishing a new Nurse Workforce and Patient Care Task Force. In follow-up to
deliberations at the Colorado Capitol addressing nurse staffing issues, the Colorado
Hospital Association (CHA) proposed establishing a task force to identify quality
measures for patient care related to nursing in order to obtain meaningful data that
could be publicly reported. Therefore, an additional 20 organizations under the
umbrella of the Colorado Hospital Association volunteered to participate in the test.

A Technical Advisory Panel (TAP) was identified to provide advice with respect to
project tools, materials and methodology, review the overall project analysis, and
recommend potential modifications to the implementation guide for national
implementation. An initial conference call with the TAP was held in May 2007 to
welcome members, introduce the project, and inform them on activities completed and
planned. In August 2007, an in-person meeting of the panel was held at Joint
Commission Headquarters. Following an update on project activities, the balance of the
day was focused on discussion of project evaluation strategies. Measurement outcomes
were discussed and refined. Measure developers also shared experiences and offered

NSC Measure Set iv


resources for extant analysis activities from active measurement initiatives where
applicable. Joint Commission statistical staff participated in these discussions.

The Joint Commission’s Nursing Advisory Council (NAC) was utilized throughout the
project as a reactor panel to review project findings. The NAC was informed of project
progress and findings during their meetings in May and October 2007, and March, June,
and September 2008. The multiple perspectives on the NAC provided insight and real
world experience to the TAP respecting the perceived effectiveness of the measures as
a set, the effect of the set in assessing and improving care, and the discrimination
capabilities of the measure set.

In spring of 2007, each measure developer was contacted to inquire about and obtain
any measure-specific changes since development of the implementation guide in 2005.
These updates were added to the technical specifications for use in testing the set. The
revised Implementation Guide for the NQF- Endorsed Nursing-Sensitive Care
Performance Measures was distributed to all volunteer test hospitals in June 2007.
Measure developers were contacted again in October 2008, so any measure updates
that occurred during the testing period could be considered by the TAP in their final
recommendations.

Site training was designed in multiple modules, over the course of the test period,
following the framework for data collection. To support a phased-in approach to data
collection, a schedule was developed based on data collection frequency and data
source. Additionally, a series of conference calls were held to provide on-going support
to organizations, as well as providing in-depth measure education. A representative of
each measure developer was invited to serve as a guest expert for the respective
discussions. Five initial training web cast/conference calls, and five training calls
including measure developers were held between June 2007 and May 2008. A training
manual was developed to act as a companion to the Implementation Guide and was
distributed to all participant test sites.

An electronic tool for data entry and transmission was developed for site use during the
test period. Sites were able to enter clinical data directly into the tool and upload
administrative data. Sites received the tool and training in September 2007.

Pilot sites began the 12 month data collection period on August 1, 2007, and continued
through July 31, 2008. Initially a July 1, 2007 start date was identified for data collection;
however in response to site requests for additional start-up time, and to have a uniform
data set between the initial 54 sites and Colorado Hospital Association (CHA)
participating sites that joined in July 2007, the start date was adjusted to August, 2007.

In June 2008, pilot sites were asked to complete a qualitative survey using an on-line
survey tool. Invitations were sent to all 74 sites that had initially enrolled in the project
inviting them to participate in the survey. The survey was used to gather qualitative data
respecting: perceived barriers and limitations to national implementation of the complete
measure set; staff effort and resource utilization to collect and transmit the required data

NSC Measure Set v


relative to the derived benefits; gaps in knowledge between nursing-related
measurement and quality of care; staff perceptions respecting the potential for this
measure set to influence improvements in nursing care; and, patient quality outcomes.

To assist in understanding resource utilization for the project, including individual
measures, each hospital was requested to complete an Activity Status Log at defined
monthly intervals between February and July, 2008. The log included information such
as total hours dedicated to specific activities, type of individuals involved in the project
by activity, and activities by individual measure. The experience and lessons learned
during the pilot project are of critical importance to the successful evaluation and
implementation of the Nursing-Sensitive Care Performance Measures.

Twenty pilot sites were randomly selected for an on-site reliability assessment. Project
staff completed 19 on-site reliability visits between April and August 2008. The first visit
was used as a trial visit and one visit was not completed due to a last minute airline
cancellation that could not be rescheduled within the needed timeframe.

From August through November 2008, the project staff analyzed data and prepared
reports based on the reliability data, qualitative survey data, activity logs, and pilot site
measure data in preparation for the November 12, 2008 TAP member meeting. At the
meeting following a detailed discussion of each individual measure there was
consensus among the TAP members to recommend that each of the measures move
forward.

The measure set went through the NQF measure maintenance review process in the
spring / summer of 2009. Eleven of the 15 measures were reviewed through this project
including: Pressure Ulcer Prevalence; Patient Falls; Falls with Injury; Restraint
Prevalence; Smoking Cessation for Acute Myocardial Infarction, Heart Failure, and
Pneumonia; Skill Mix; Nursing Hours Per Patient Day; Voluntary Turnover; and the
PES-NWI survey. The NQF Consensus Standards Approval Committee and Board
approved continued endorsement of 8 measures including: Pressure Ulcer Prevalence;
Patient Falls; Falls with Injury; Restraint Prevalence; Skill Mix; Nursing Hours Per
Patient Day; Voluntary Turnover; and the PES-NWI survey. Smoking Cessation for
Acute Myocardial Infarction, Heart Failure, and Pneumonia were approved for
retirement. The Death Among Surgical Inpatients with Serious Treatable Complications
measure was revised and endorsed in May 2008. The device related infection
measures Urinary Catheter-Associated Urinary Tract Infections, Catheter-Associated
Blood Stream Infection, and Ventilator-Associated Pneumonia measures are scheduled
for review by the NQF at a later date.

The Implementation Guide for the NQF- Endorsed Nursing-Sensitive Care
Performance Measures Version 2.0 includes those measures approved for
continued endorsement and reflects updates to the guide as a result of the
comprehensive testing.

NSC Measure Set vi


Using the Technical Implementation Guide for the

This portion of the implementation guide provides a brief overview of the information
contained within each section of the manual. It is intended for use as a quick reference
to assist health care organizations and others in the implementation of the nursing-
sensitive care performance measures. The sections of the manual are interrelated and
are most useful when considered together.

Introduction - Framework
This section provides background information about the framework developed by the
Nursing-Sensitive Care Performance Measures Steering Committee and reviewed by a
three member Technical Advisory Panel under the auspices of the National Quality
Forum (NQF) Consensus Development Process. It describes principles underlying
framework development and provides a visual representation.

Section 1 – Data Dictionary
The Data Dictionary describes the record-level data elements required to capture and
calculate individual measurements. It specifies those data elements that must be
collected for each measure in the set.

Section 2 – Measure Information
This section provides a Measure Information Form (MIF) for each measure in the set.
The MIF contains detailed information about the measure such as measure type (e.g.,
rate-based proportion versus continuous variable), population description (e.g.,
inclusions and exclusions) and required data elements.

Appendix A – Glossary of Terms
This section provides definitions for terms used in the measure set.

Appendix B – Overview of Measure Information Form and Flowchart Formats
For each measure in the nursing-sensitive care set listed in this guide, there is a
Measure Information Form. This appendix explains each of the terms used on the
Measure Information Form (MIF).

Appendix C – Resources
This appendix contains available resources to those using this manual.

Appendix D - Miscellaneous Tables
These tables contain clinical information to supplement the data element dictionary and
provide additional details for data collection and abstraction.

Appendix E – Prevalence Study Methodology
This Appendix contains clinical information to supplement the data element dictionary
and provide additional details for data collection and abstraction during the prevalence
study.

NSC Measure Set


Appendix F – Device Related Infection Measure Criteria
This Appendix contains clinical information to supplement the data element dictionary
and provide additional details for data collection and abstraction of the device related
infection measures.

Appendix G – PES-NWI Nurse Survey
This Appendix contains the PES-NWI nursing survey questionnaire.

NSC Measure Set


Measure Set List and Descriptors


1) Death Among Surgical Inpatients with Treatable Serious Complications

2) Pressure Ulcer Prevalence (Hospital-Acquired)

3) Restraint Prevalence (vest and limb)

4) Patient Falls

5) Falls with Injury

6) Catheter-Associated Urinary Tract Infection (CAUTI) Rate for Intensive Care Unit
(ICU) Patients

7) Central Line Catheter-Associated Bloodstream Infection (CLABSI) Rate for
Intensive Care Unit (ICU) and Neonatal Intensive Care Unit (NICU) Patients

8) Ventilator-Associated Pneumonia (VAP) Rate for Intensive Care Unit (ICU) and
Neonatal Intensive Care (NICU) Patients

9) Skill Mix

10) Nursing Care Hours per Patient Day

11) Voluntary Turnover

12) Practice Environment Scale-Nursing Work Index (PES-NWI)

NSC Measure Set


Measure Set Descriptors

Measure Measure Measure Data Unit of Data Calculation
ID Type Population Source Analysis Collection Frequency
Frequency
NSC 1 Clinical Patient Medical Hospital- Monthly Quarterly
Surgical (Incidence) Record level
Deaths
NSC 2 Clinical Patient Prevalence Unit -level Quarterly Quarterly
Pressure (Prevalence) Survey
Ulcer Medical
Prevalence Record
NSC 3 Clinical Patient Prevalence Unit-level Quarterly Quarterly
Restraint (Prevalence) Survey
Prevalence Medical
Record
NSC 4 Clinical Patient Medical Unit-level Monthly Quarterly
Patient (Incidence) Record
Falls
Falls with (Incidence) Record
Injury
CAUTI (Incidence) Record

CLABSI (Incidence)) Record

VAP (Incidence) Record

NSC 9 Administrative Nursing Human Unit-level Monthly Quarterly
Skill Mix Resources Resources,
Payroll
NSC 10 Administrative Nursing Medical Unit-level Monthly Quarterly
Nursing Resources Record
Hours Human
Resources
NSC 11 Administrative Nursing Human Hospital- Monthly Quarterly
Voluntary Resources Resources, level *
Turnover Payroll
NSC 12 Perception Nurses Survey Hospital- Annual Annual
PES-NWI (Environment) level *

* Note: Measures may be analyzed at the unit level, however are publicly reported at the
hospital level only.

NSC Measure Set


Data Dictionary

Introduction

This section of the manual describes the data elements required to calculate category
assignments and measurements for the nursing sensitive care performance measures.
It includes information necessary for defining and formatting the data elements, as well
as the allowable values for each data element. This information is intended to assist in
processing data elements for national quality measures.

It is of primary importance that all hospitals using nursing sensitive care performance
measures gather and utilize the data elements as defined in this section. This will
ensure that the data are standardized and comparable across hospitals.

Certain general data elements are collected by the hospital and submitted for every
patient that falls into selected initial patient populations. These data elements are
considered “general” to each episode of care.

These data elements include:
• Admission Date
• Birthdate
• Hospital Patient Identifier
• Sex

Data elements that are general for every patient that fall into measures that are reported
at time of discharge include:
• Admission Source
• Discharge Date
• Discharge Status
• ICD-9-CM Other Diagnosis Codes
• ICD-9-CM Other Procedure Codes
• ICD-9-CM Other Procedure Dates
• ICD-9-CM Principal Diagnosis Code
• ICD-9-CM Principal Procedure Code
• ICD-9-CM Principal Procedure Date
• Payment Source
• Point of Origin for Admission or Visit

Data elements that are general for every patient that falls into measures that are
reported at the time of the event include:
• Date of Event
• Event Identifier
• Event Type

NSC Measure Set Introduction to the Data Dictionary -1


Episode of Care
An Episode of Care (EOC) is defined as the health care services given during a certain
period of time, usually during a hospital stay (e.g., from the day of arrival or admission
to the day of discharge).
For Joint Commission measure reporting, if a patient is transferred from an acute care
hospital to another acute care hospital, which is within the same healthcare system and
shares the same Joint Commission Health Care Organization Identifier (HCO ID), this
should be abstracted as one episode of care.

Data Integrity

Editing ‘Date’ and ‘Time’ Data Elements
Performing simple edits between ‘date’ and ‘time’ data elements will help ensure data
integrity.
• Dates must be recorded in the following format: MM-DD-YYYY.
Example:
July 4, 2006 would be recorded as 07-04-2006
• Time must be recorded in military time format.
Example:
3:00 p.m. would be recorded as 15:00
Note:
00:00 = midnight. When converting 24:00 to 00:00 do not forget to change the date
Example:
Midnight or 24:00 on 11-24-2006 = 00:00 on 11-25-2006
• For times that include “seconds”, remove the seconds and record the time as is.
Example:
15:00:35 would be recorded as 15:00
Editing Zero Values
Verification mechanisms are necessary to assure that zero is the intended data value
rather than an initialization value for those data elements which have an allowable value
of zero (i.e., 0.0, 0000, 0).

Missing and Invalid Data
Each data element that is applicable for the calculation of each of the measures must
be “touched” by the abstractor. While this is the expectation, it is recognized that in
certain situations information may not be available (e.g., dates, times, codes, etc.). After
due diligence in reviewing all allowable data sources within the data source, if the
abstractor determines that a value is not documented, i.e. “missing,” or is unable to
determine if a value is documented, the abstractor should select the “UTD - Unable to
Determine,” value. The data elements Admission Date, Discharge Date and Birthdate
require an actual date for submission into the data entry tool and “UTD” cannot be
selected as an allowable value. For Yes/No values the allowable value “No”
incorporates the “UTD” into the definition. For data elements containing more than two
categorical values and for numerical data elements (i.e., dates, times, laboratory values,
etc.), a “UTD” option is included as an allowable value and is classified in the same



category as not documented. Files that contain any invalid and/or missing data will be
rejected.

Interpreting Data Element Definitions and Allowable Values
Every attempt has been made to comprehensively define the nursing-sensitive care
performance measure data elements and allowable values in a manner that obviates
the need for interpretation. If, after reviewing the General Abstraction Guidelines, the
data element definition, including the notes and guidelines for abstraction, an abstractor
cannot clearly assign an allowable value, refer to Resources, Appendix C for additional
contact information.

Interpretation of Data Dictionary Terms
The measures in this set fall within three framework categories:
• patient-centered outcome measures;
• nursing-centered intervention measures; and
• system-centered measures.

The type and sources of data will vary significantly across these categories. However,
regardless of the category of the measure, all data elements have been presented in a
consistent format and have been standardized within the set wherever possible.
Therefore, the consistent application of these data element specifications across health
care organizations would build the foundation for national-level standardization of the
nursing-sensitive measure set. This will support the use of this measure set for external
comparison between organizations.

Data Element Dictionary Terms

Data Element Name: A short phrase identifying the data element.

Collected For: Identifies the measure(s) that utilize this data element or
specifies that the data element is used for data transmission.

Definition: A detailed explanation of the data element.

Suggested Data
Collection Question: A suggested wording for a data element question in a data
abstraction tool.

Format: Length = number of characters or digits allowed
for the data element
Type = type of information the data element
contains (i.e., numeric, alphanumeric, date,
decimal, or time)



Occurs = the number of times the data element occurs in
a single episode of care record

Allowable Values: A list of acceptable responses for this data element

Notes for Abstraction: Provided to assist abstractor in the selection of appropriate
value for a data element

Suggested Data Sources: Source document from which data can be identified such as
administrative or medical record. Some data elements also
list excluded data sources that are unacceptable sources for
collecting information.

Guidelines for Abstraction: Designed to assist abstractors in determining how a data
element should be answered

Note: Element specific notes and guidelines should take
precedence over the General Abstraction Guidelines.

General Abstraction Guidelines

The General Abstraction Guidelines are a resource designed to assist abstractors in
determining how a question should be answered. The abstractor should first refer to the
specific notes and guidelines under each data element. These instructions should take
precedence over the following General Abstraction Guidelines. All of the allowable
values for a given data element are outlined, and notes and guidelines are often
included which provide the necessary direction for abstracting a data element. It is
important to utilize the information found in the notes and guidelines when entering or
selecting the most appropriate answer.

Medical Record Documentation
The intent of abstraction is to use only documentation that was part of the medical
record during the hospitalization (is present upon discharge) and that is present at the
time of abstraction. There are instances where an addendum or late entry is added after
discharge. This late entry or addendum can be used, for abstraction purposes, as long
as it has been added within 30 days of discharge, unless otherwise specified in the data
element. It is not the intent to have documentation added at the time of abstraction to
ensure the passing of a measure.
Important Note: There are several data elements where abstraction of data from
documentation dated/timed after discharge is restricted, and these exceptions are
published on the respective data element pages of the data dictionary. Data element
specific notes and guidelines always take precedence over the General Abstraction
Guidelines.
All documentation in the medical record must be legible and must be timed, dated and
authenticated. When abstracting a medical record, if a handwritten document is



determined to be not legible, other documentation should be reviewed in an attempt to
obtain the answer. If no other source document is able to verify the handwritten
documentation, only then is the abstractor to answer unable to determine from the
medical record documentation, unless otherwise specified in the data element.
Authentication may include written signatures, initials, computer key, or other codes.
Data element information should be retrieved from the current medical record, covering
the admission and discharge date, or reporting period for event measures being
abstracted. Information ascertainable from previous history (e.g., failed trials of
monotherapy) AND determined to be part of the current medical record may be used in
abstraction. For example, if the patient had previously failed three or more trials of
monotherapy and this information is available in the current chart being abstracted (e.g.,
a note made in the continuing care plan), this information should be used. Previous
history information used in abstraction should be information that was part of the
medical record during hospitalization, when care was being delivered.
The medical record must be abstracted as documented (taken at “face value”). When
the value documented is obviously in error (not a valid format/range or outside of the
parameters for the data element) and no other documentation is found that provides
this information, the abstractor should select “UTD.” Example:
• Patient expires on 02-12-20XX and documentation indicates the Event Date was
03-12-20XX. Other documentation in the medical record supports the date of
death as being accurate. Since the Event Date is after the Discharge Date
(death), it is outside of the parameter of care and the abstractor should select
“UTD.”
Note: Hospitals should use abbreviations according to their policy. Frequently flow
sheets or other documentation contain a ‘key or legend’ that explains what the
abbreviation or symbol stands for, especially if unique to that facility.

Suggested Data Sources
• Suggested Data Sources are listed in alphabetical order, NOT priority order, unless
otherwise specified.
• Suggested Data Sources are designed to provide guidance to the abstractor as to
the locations/sources where the information needed to abstract a data element will
likely be found. However, the abstractor is not limited to these sources for
abstracting the information and is encouraged to review the entire medical record
unless otherwise specified in the data element.
• In the course of abstraction, if conflicting information is found in a source other than
the suggested data sources, and use of this source is not restricted, consider using
this information if it more accurately answers the question, unless otherwise
specified.
Example:
The nursing notes state the patient experienced a fall, and the incident report states
the fall occurred while in the radiology department. The notes from radiology, while
not listed as a suggested data source, more accurately describe the fall location and
should be used for identifying fall location when counting falls for a given unit.



• If, after due diligence, the abstractor determines that a value is not documented or
is not able to determine the answer value, the abstractor must select “Unable to
Determine (UTD)” as the answer.
• Hospitals often label forms and reports with unique names or titles. Suggested Data
Sources are listed by commonly used titles; however, information may be abstracted
from any source that is equivalent to those listed.
Example:
If the “nursing admission assessment” is listed as a suggested source, an
acceptable alternative might be titled “nurses initial assessment” or “nursing data
base.”
Note:
Element specific notes and guidelines should take precedence over the General
Abstraction Guidelines.

Inclusions/Exclusions
• Inclusions are “acceptable terms” that should be abstracted as positive findings
(e.g., “Yes”).
• Inclusion lists are limited to those terms that are believed to be most commonly used
in medical record documentation. The list of inclusions should not be
considered all-inclusive, unless otherwise specified in the data element.
• Exclusions are “unacceptable terms” that should be abstracted as negative
findings (e.g., “No”)
• Exclusion lists are limited to those terms an abstractor may most frequently question
whether or not to abstract as a positive finding for a particular element (e.g.,
“restraints” that are only associated with medical, dental, diagnostic, or surgical
procedures and is based on standard practice for the procedure (sometimes referred
to as treatment restraints) should not be counted as a restraint for the prevalence
study). The list of exclusions should not be considered all-inclusive, unless
otherwise specified in the data element.
• When both an inclusion and exclusion are documented in a medical record, the
inclusion takes precedence over the exclusion and would be abstracted as a positive
finding (e.g., answer “Yes”), unless otherwise specified.

Physician/Advanced Practice Nurse/ Physician Assistant Documentation
• Advanced Practice Nurse (APN, APRN) titles may vary between state and clinical
specialities. Some common titles that represent the advanced practice nurse role
are:
• Nurse Practitioner (NP)
• Certified Registered Nurse Anesthetist (CRNA)
• Clinical Nurse Specialist (CNS)
• Certified Nurse Midwife (CNM)
• When a physician/advanced practice nurse/ physician assistant (physician/APN/PA)
signs a form or report (e.g., ED sheet with triage and nursing information and a
physician/APN/PA has signed somewhere on the form), information on that
form/report should be considered physician/APN/PA documentation.



• “Rubber” stamped physician/advanced practice nurse/physician assistant
(physician/APN/PA) signatures are not acceptable on any document within the
medical record. Handwritten, electronic signatures, facsimiles of original written or
electronic signatures are acceptable.
• Resident and intern notes should be considered physician documentation. Medical
student notes must be co-signed by a physician.

Pharmacist Documentation
Pharmacist titles may vary. Some common titles that represent the pharmacist role are:
• Doctor of Pharmacy (Pharm.D. or D.Ph.)
• Registered Pharmacist (R.Ph.)

Medications:
• Whether or not a medication has been administered to a patient is often clear
when using medical record sources such as medication administration records,
but documentation can be more ambiguous in other sources, namely, physician
orders, ED records, and ambulance records. To make a determination using
these sources, use the following criteria:
o For EHRs only accept documentation that reflects the actual
administration of the medication in the context of the chart.
o If a medication in the physician orders has been initialed and signed off
with a time, do NOT presume that the medication was administered. The
documentation MUST indicate that the medication was actually given.
o For an ED or ambulance record, there is no need for documentation
indicating that the medication was actually given.
Example:
If the ED or ambulance record reflects “ASA 325mg po 13:00” and
no other documentation exists indicating that the medication was
actually given (e.g., “given” or “administered”), this is acceptable
documentation to abstract.

Diagnostic/Laboratory Tests
Whether or not a diagnostic or laboratory test has been done is usually clear when
using medical record sources such as diagnostic test reports, laboratory reports, or
progress notes (where a physician might note test findings), but documentation can be
more ambiguous in other sources, namely, physician orders and ED records. To make a
determination using these sources, use the following criteria:
• If a test in the physician orders has been initialed and signed off with a time, do
NOT presume that the test was done. The documentation MUST indicate that the
test was actually done (e.g., accompanied by a word such as “done”).
• For an ED record, there is no need for explicit documentation indicating that the
test was actually done. For example, if an ED record notes “Lipid profile,” and
this is followed by a signature and/or a time, the abstractor should presume the
test was performed.



Data Elements by Measure List

NSC-1 Death Among Surgical Inpatients with Treatable Serious Complications
Admission Date
Admission Type
Birthdate
Diagnosis-Related Groups
Discharge Date
Discharge Status
Hospital Patient Identifier
ICD-9-CM Other Diagnosis Codes
ICD-9-CM Other Procedure Codes
ICD-9-CM Other Procedure Dates
ICD-9-CM Principal Diagnosis Code
ICD-9-CM Principal Procedure Code
ICD-9-CM Principal Procedure Date
Major Diagnostic Category (MDC)
Payment Source
Point of Origin for Admission or Visit
Sex
NSC-2 Pressure Ulcer Prevalence (Hospital-Acquired)
Admission Date
Birthdate
Observed Pressure Ulcer - Hospital Acquired
Observed Pressure Ulcer – Category/stage
Observed Pressure Ulcer(s)
Sex
Type of Unit
NSC-3 Restraint Prevalence (vest and limb)
Admission Date
Birthdate
Physical Restraint
Prevalence Study Date
Sex
Type of Restraint
Type of Unit
NSC-4 Patient Falls
Admission Date
Birthdate
Date of Event
Event Identifier
Event Type

NSC Measure Set Data Elements by Measure List -1


Month
Number of Patient Falls
Patient Days
Sex
Type of Unit
Year
NSC-5 Falls with Injury
Admission Date
Birthdate
Date of Event
Event Identifier
Event Type
Fall Injury Level
Month
Patient Days
Sex
Type of Unit
Year
NSC-6 Catheter-Associated Urinary Tract Infections
Admission Date
Birthdate
Date of Event
Device
Event Identifier
Event Type
Indwelling Urinary Catheter Days
Location
Location of Attribution
Month
Sex
Specific Event Type
Year
NSC-7 Central Line Catheter-Associated Blood Stream Infections
Admission Date
Birth Weight
Birthdate
Central Line Days – ICU
Central Line Days – NICU
Date of Event
Device
Event Identifier
Event Type



Location
Month
Sex
Specific Event Type
Umbilical Catheter Days
Year
NSC-8 Ventilator-Associated Pneumonia
Admission Date
Birth Weight
Birthdate
Date of Event
Device
Event Identifier
Event Type
Location
Month
Sex
Specific Event Type
Ventilator Days
Year
NSC-9 Skill Mix
LPN/LVN Hours [Contract/Agency]
LPN/LVN Hours [Employee]
Month
RN Hours [Contract/Agency]
RN Hours [Employee]
Type of Unit
UAP Hours [Contract/Agency]
UAP Hours [Employee]
Year
NSC-10 Nursing Hours Per Patient Day
LPN/LVN Hours [Contract/Agency]
LPN/LVN Hours [Employee]
Month
Patient Days
RN Hours [Contract/Agency]
RN Hours [Employee]
Type of Unit
Year



NSC-11 Voluntary Turnover
Employed APNs
Employed LPN/LVNs
Employed RNs
Employed UAP
Month
Reason for Separation
Separations APN
Separations LPN /LVN
Separations UAP
Separations RN
Type of Unit
Year
NSC-12 Practice Environment Scale – Nursing Work Index
Number of Responses
PES-NWI Adequate Support Services
PES-NWI Administration Listens and Responds
PES-NWI Advancement Opportunities
PES-NWI Career Development
PES-NWI Chief Nursing Officer Authority
PES-NWI Chief Nursing Officer Visibility
PES-NWI Collaboration
PES-NWI Continuing Education
PES-NWI Continuity of Patient Assignments
PES-NWI Enough Nurses for Quality Care
PES-NWI Enough Staffing
PES-NWI High Nursing Care Standards
PES-NWI Nurse and Physician Relationships
PES-NWI Nurse and Physician Teamwork
PES-NWI Nurse Manager and Leader
PES-NWI Nurse Manager Backs up Staff
PES-NWI Nurses Are Competent
PES-NWI Nursing Administrators Consult
PES-NWI Nursing Care Models
PES-NWI Nursing Committees
PES-NWI Nursing Diagnosis
PES-NWI Participation in Policy Decisions
PES-NWI Patient Care Plans
PES-NWI Philosophy of Nursing
PES-NWI Preceptor Program
PES-NWI Quality Assurance Program
PES-NWI Recognition
PES-NWI Staff Nurses Hospital Governance
PES-NWI Supervisors Learning Experiences
PES-NWI Supportive Supervisory Staff



PES-NWI Time to Discuss Patient Problems
Survey Date
Survey Distribution Date
Total Number of Nurses Surveyed
Total Number of Surveys
Type of Unit



Alphabetical Data Dictionary

The General Abstraction Guidelines explain the different sections of the data element
definitions and provide direction for common questions and issues that arise in medical
record abstraction. Instructions in the specific data elements in this Data Dictionary
should ALWAYS supersede those found in the General Abstraction Guidelines.

Element Name Collected For:
Admission Date NSC 1, 2, 3, 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2
Admission Type NSC 1
Birth Weight NSC 7.2, 7.3, 8.2
Birthdate NSC 1, 2, 3, 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2
Central Line Days – ICU NSC 7.1
Central Line Days – NICU NSC 7.2
Date of Event NSC 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2
Device NSC 6, 7.1, 7.2, 7.3, 8.1, 8.2
Diagnosis-Related Groups NSC 1
Discharge Date NSC 1
Discharge Status NSC 1
Employed APNs NSC 11.1
Employed LPN/LVNs NSC 11.2
Employed RNs NSC 11.1
Employed UAPs NSC 11.3
Event Identifier NSC 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2
Event Type NSC 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2
Fall Injury Level NSC 5
Hospital Patient Identifier NSC 1, 2, 3, 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2
ICD-9-CM Other Diagnosis Codes NSC 1
ICD-9-CM Other Procedure Codes NSC 1
ICD-9-CM Other Procedure Dates NSC 1
ICD-9-CM Principal Diagnosis Code NSC 1
ICD-9-CM Principal Procedure Code NSC 1
ICD-9-CM Principal Procedure Date NSC 1
Indwelling Urinary Catheter Days NSC 6
Location NSC 6, 7.1, 7.2, 7.3, 8.1, 8.2
Location of Attribution NSC 6, 7.1, 7.2, 7.3, 8.1, 8.2
LPN/LVN Hours [Contract/Agency] NSC 9.1, 9.2, 9.3, 9.4, 10.2
LPN/LVN Hours [Employee] NSC 9.1, 9.2, 9.3, 9.4, 10.2
Major Diagnostic Category (MDC) NSC 1
Month NSC 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2, 9.1,
9.2, 9.3, 9.4, 10.1, 10.2, 11.1, 11.2, 11.3
Number of Patient Falls NSC 4
Number of Responses NSC 12
Observed Pressure Ulcer - Hospital NSC 2
Acquired

NSC Measure Set Alphabetical Data Dictionary-1


Observed Pressure Ulcer – Category/stage NSC 2
Observed Pressure Ulcer(s) NSC 2
Patient Days NSC 4, 5, 10.1, 10.2
Payment Source NSC 1
PES-NWI Adequate Support Services NSC 12
PES-NWI Administration Listens and NSC 12
Responds
PES-NWI Advancement Opportunities NSC 12
PES-NWI Career Development NSC 12
PES-NWI Chief Nursing Officer Authority NSC 12
PES-NWI Chief Nursing Officer Visibility NSC 12
PES-NWI Collaboration NSC 12
PES-NWI Continuing Education NSC 12
PES-NWI Continuity of Patient NSC 12
Assignments
PES-NWI Enough Nurses for Quality Care NSC 12
PES-NWI Enough Staffing NSC 12
PES-NWI High Nursing Care Standards NSC 12
PES-NWI Nurse and Physician NSC 12
Relationships
PES-NWI Nurse and Physician Teamwork NSC 12
PES-NWI Nurse Manager and Leader NSC 12
PES-NWI Nurse Manager Backs up Staff NSC 12
PES-NWI Nurses Are Competent NSC 12
PES-NWI Nursing Administrators Consult NSC 12
PES-NWI Nursing Care Model NSC 12
PES-NWI Nursing Committees NSC 12
PES-NWI Nursing Diagnosis NSC 12
PES-NWI Participation in Policy Decisions NSC 12
PES-NWI Patient Care Plans NSC 12
PES-NWI Philosophy of Nursing NSC 12
PES-NWI Preceptor Program NSC 12
PES-NWI Quality Assurance Program NSC 12
PES-NWI Recognition NSC 12
PES-NWI Staff Nurses Hospital NSC 12
Governance
PES-NWI Supervisors Learning NSC 12
Experiences
PES-NWI Supportive Supervisory Staff NSC 12
PES-NWI Time to Discuss Patient NSC 12
Problems
Physical Restraint NSC 3
Point of Origin for Admission or Visit NSC 1
Prevalence Study Date NSC 2, 3
Reason for Separation NSC 11.1, 11.2, 11.3



RN Hours [Contract/Agency] NSC 9.1, 9.2, 9.3, 9.4, 10.1, 10.2
RN Hours [Employee] NSC 9.1, 9.2, 9.3, 9.4, 10.1, 10.2
Separations APN NSC 11.1
Separations LPN /LVN NSC 11.2
Separations UAP NSC 11.3
Separations RN NSC 11.1
Sex NSC 1, 2, 3, 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2
Specific Event Type NSC 6, 7.1, 7.2, 7.3, 8.1, 8.2
Survey Date NSC 12
Survey Distribution Date NSC 12
Total Number of Nurses Surveyed NSC 12
Total Number of Surveys NSC 12
Type of Restraint NSC 3
Type of Unit NSC 2, 3, 4, 5, 9.1, 9.2, 9.3, 9.4, 10.1,
10.2, 11.1, 11.2, 11.3, 12
UAP Hours [Contract/Agency] NSC 9.1, 9.2, 9.3, 9.4, 10.2
UAP Hours [Employee] NSC 9.1, 9.2, 9.3, 9.4, 10.2
Umbilical Catheter Days NSC 7.3
Ventilator Days NSC 8.1, 8.2
Year NSC 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2, 9.1,
9.2, 9.3, 9.4, 10.1, 10.2, 11.1, 11.2, 11.3



Data Element Name: Admission Date

Collected For: NSC 1, 2, 3, 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2

Definition: The month, day, and year of admission to acute inpatient
care.

Suggested Data
Collection Question: What is the date the patient was admitted to acute inpatient
care?

Format: Length: 10 – MM-DD-YYYY (includes dashes)
Type: Date
Occurs: 1

Allowable Values: MM = Month (01-12)
DD = Day (01-31)
YYYY = Year (2001 – Current Year)

Notes for Abstraction: • The intent of this data element is to determine the date
that the patient was actually admitted to acute inpatient
care. Because this data element is critical in determining
the population for all measures, the abstractor should
NOT assume that the claim information for the admission
date is correct. If the abstractor determines through chart
review that the date is incorrect, for purposes of
abstraction, she/he should correct and override the
downloaded value.
• A patient of a hospital is considered an inpatient upon
issuance of written doctor’s orders to that effect. (Refer
to the Medicare Claims Processing Manual, Chapter 3,
Section 40.2.2.)
• For patients who are admitted to Observation status and
subsequently admitted to acute inpatient care, abstract
the date that the determination was made to admit to
acute inpatient care and the order was written. Do not
abstract the date that the patient was admitted to
Observation.
• For patients that are admitted for surgery and/or a
procedure, if the admission order states the date the
orders were written and they are effective for the
surgery/procedure date, then the date of the
surgery/procedure would be the admission date. If the
medical record reflects that the admission order was
written prior to the actual date the patient was admitted
and there is no reference to the date of the



surgery/procedure, then the date the order was written
would be the admission date.

Suggested Data PRIORITY ORDER FOR THESE SOURCES
Sources: • Physician orders
• Face Sheet
• UB-04, Field Location: 12

Guidelines for Abstraction:
Inclusion Exclusion
None • Admit to observation
• Arrival date



Data Element Name: Admission Type

Collected For: NSC-1

Definition: The code indicating priority/type of admission.

Suggested Data
Collection Question: What was the priority/type of admission?

Format: Length: 1
Type: Alphanumeric
Occurs: 1

Allowable Values: 1 Emergency
The patient requires immediate medical intervention as a
result of severe, life threatening, or potentially disabling
conditions.

2 Urgent
The patient requires immediate attention for the care and
treatment of a physical or mental disorder.

3 Elective
The patient's condition permits adequate time to
schedule the services.

4 Newborn
Use of this code necessitates the use of special Source
of Admission/Point of Origin codes -- see data element
Point of Origin for Admission or Visit.

5 Trauma Center
Visit to a trauma center/hospital as licensed or
designated by the state or local government authority
authorized to do so, or as verified by the American
College of Surgeons and involving a trauma activation.

9 Information not available

Notes for Abstraction: If unable to determine admission type, select “9.”

Suggested Data • Emergency department record
Sources: • Face sheet
• History and physical
• Progress notes



Inclusion Exclusion
None None



Data Element Name: Birth Weight

Collected For: NSC-7.2, 7.3, 8.2

Definition: The weight (in grams) of a neonate at the time of delivery.

Note:
453.5 grams = 1 pound
28.35 grams = 1 ounce
It is recommended that each system provide the ability to
enter birth weight in either grams or pounds. However, all
birth weights must be converted to grams prior to indicator
calculation.

Suggested Data
Collection Question: What was the weight of the neonate at delivery?

Format: Length: 4 or UTD
Type: Alphanumeric
Occurs: 1

Allowable Values: 150 through 8165 grams
UTD = Unable to Determine

Note:
When converting from pounds and ounces to grams, do not
round to the nearest pound before converting the weight to
grams. Round to the nearest whole number after the
conversion to grams.

Notes for Abstraction: • Birth weights less than 150 grams need to be verified that
the baby was live born and for data quality purposes.
Birth weights greater than 8165 grams need to be verified
for data quality.
• If the birth weight is unable to be determined from
medical record documentation, enter UTD.
• The medical record must be abstracted as documented
(taken at “face value”). When the value documented is
not a valid number/value per the definition of this data
element and no other documentation is found that
provides this information, the abstractor should select
“UTD.”
Example:
Documentation indicates the Birth Weight was 0 grams.
No other documentation in the medical record provides a
valid value. Since the Birth Weight is not a valid value,



Notes for Abstraction the abstractor should select “UTD.”
continued: Note:
Transmission of a case with an invalid value as described
above will be rejected from the Joint Commission’s Data
Warehouse. Use of “UTD” for Birth Weight allows the
case to be accepted into the warehouse.

Suggested Data • Delivery record
Sources: • History and physical
• Nursing notes
• Nursery record
• Progress notes

Inclusion Exclusion
None None



Data Element Name: Birthdate


Definition: The month, day, and year the patient was born.

Note:
Patient's age (in years) is calculated by Admission Date
minus Birthdate. The algorithm to calculate age must use
the month and day portion of admission date and birthdate to
yield the most accurate age.

Suggested Data
Collection Question: What is the patient’s date of birth?

Type: Date
Occurs: 1

DD = Day (01-31)
YYYY = Year (1880-Current Year)

Notes for Abstraction: Because this data element is critical in determining the
population for all measures, the abstractor should NOT
assume that the claim information for the birthdate is correct.
If the abstractor determines through chart review that the
date is incorrect, she/he should correct and override the
downloaded value. If the abstractor is unable to determine
the correct birthdate through chart review, she/he should
default to the date of birth on the claim information.

• Registration form

Inclusion Exclusion
None None



Data Element Name: Central Line Days – ICU

Collected For: NSC 7.1

Definition: Any day that a patient has a central line in place at the time
the count is done. A patient with multiple central lines in
place on a given day should be counted as one central line
day. This daily count is aggregated / summed across the
days of the month to provide the total number of central line
days for the month for each individual ICU Location.

Suggested Data
Collection Question: What is the total number of central line days for this ICU
location for the month?

Format: Length: 5
Type: Alphanumeric
Occurs: 1 per strata (One aggregate count is expected for
each report stratum or birth weight category)

Allowable Values: 0 – 99999

Notes for Abstraction:
• Central line days should be counted in a consistent
manner (e.g., at the same time each day).
• A separate Central Line Days total is collected for each
ICU Location

Suggested Data
Sources:
• Direct observation
• Nursing notes
• Progress notes
• Radiographic record showing the catheter tip location

Inclusion Exclusion
• Peripherally inserted central line • Peripheral venous catheters (short)
venous catheters (PICC) • Peripheral arterial catheters
• Tunneled central line venous • Midline catheters
catheters • Pacemaker wires and other non-
• Nontunneled central venous infusion devices inserted into central
catheters blood vessels or the heart are not
• Totally implantable catheters: considered central lines
implanted in subclavian or internal
jugular vein



• Femoral lines
• Pulmonary artery catheters when
used for infusion



Data Element Name: Central Line Days – NICU


Definition: Any day that a neonate has a central line in place at the time
the count is done. A patient with multiple central lines in
place on a given day should be counted as one central line
day. This daily count is aggregated / summed across the
days of the month to provide the total number of central line
days for the month for each birth weight category.

Suggested Data
Collection Question: What is the total number of central line days in the NICU for
this Birth weight category for the month?

Format: Length: 5
Type: Numeric

Allowable Values: 0 - 99999

• Central line days should be counted in a consistent
• A patient with a central line AND an umbilical catheter
should be counted as having one umbilical catheter day.
• A separate central line count is collected for each birth
weight category

Suggested Data Sources:
• Direct Observation
• Nursing notes
• Operative record
• Progress notes

Inclusion Exclusion
• Peripherally inserted central venous • Peripheral venous catheters (short)
catheters (PICC) • Peripheral arterial catheters
• Tunneled central venous catheters • Midline catheters
• Nontunneled central venous catheters • Pacemaker wires and other non-
• Totally implantable catheters: infusion devices inserted into the
implanted in subclavian or internal central blood vessels or the heart
jugular vein are not considered central lines



• Femoral lines
• Pulmonary artery catheters when used
for infusion



Data Element Name: Date of Event

Collected For: NSC 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2

Definition: The date the associated event type occurred.

Suggested Data
Collection Question: What is the date of the associated event type occurred?

Type: Date
Occurs: 5

DD = Day (01-31)

• For infection events use the date the first clinical
evidence of infection appeared or the date the specimen
used to make the diagnosis was collected, whichever
comes first.
• When the date of a positive culture or other laboratory
test is used as the infection date, record the date the
specimen was collected rather than the date the result
was reported by the laboratory.
• When an infection related to the patient’s stay in the
ICU/NICU becomes evident within 48 hours after the
patient’s discharge from the ICU/NICU, record the date
the patient was transferred or discharged from the
ICU/NICU as the infection date.
• Record the date using the format: mm, dd, yyyy where
mm dd yyyy are the month, day and year.

• Event Reports
• Incident Reports
• Laboratory slips
• Nursing notes
• Progress notes
• Variance Reports

Inclusion Exclusion
None None



Data Element Name: Device

Collected For: NSC 6, 7.1, 7.2, 7.3, 8.1, 8.2

Definition: Documentation that the patient had an indwelling urinary
catheter, a central line, an umbilical catheter or was on a
ventilator.

Suggested Data
Collection Question: Did the patient have an indwelling urinary catheter, central
line, umbilical catheter or ventilator in place at the time of or
during the 48 hour period before the Date of Event?

Format: Length: 1
Type: Alphanumeric
Occurs: 1

Allowable Values: 1 Central line
2 Indwelling urinary catheter (urethral)
3 Umbilical catheter
4 Ventilator
5 UTD

• Do not count central lines/umbilical catheters that were
not in place within 48 hours of the event
• Do not count ventilators that were not in place within 48
hours of the event
• Do not count urinary catheters that were not in place
within 48 hours of the event

• Laboratory slips
• Nursing Notes
• Progress notes
• Respiratory therapy notes



Inclusion Exclusion
Central Line: Central Line:
Peripherally inserted central venous Peripheral venous catheters
catheters (PICC) (short)
Tunneled central venous catheters Peripheral arterial catheters
Nontunneled central venous Midline catheters
catheters Pacemaker wires and other
Totally implantable catheters: non-infusion devices inserted
implanted in subclavian or internal into the central blood vessels
jugular vein or the heart are not considered
Femoral lines central lines
Pulmonary artery catheters when Indwelling Urinary Catheter (Urethral):
used for infusion Do not count straight in –and-
Umbilical catheters inserted through out catheters or catheters not
the umbilical artery/vein in NICU inserted into the urinary
patients bladder through the urethra.
Indwelling Urinary Catheter (Urethral): Ventilator:
A drainage tube that is inserted into Lung expansion devices such
the urinary bladder through the as intermittent positive
urethra, is left in place, and is pressure breathing airway
connected to a closed collection pressure (CPAP, hypoCPAP)
system; also called a Foley catheter. are not considered ventilators
Ventilator: unless delivered via
Lung expansion device to assist or tracheostomy or endotracheal
control respiration continuously intubation (e.g., ET-CPAP).
through a tracheostomy or by
endotracheal intubation



Data Element Name: Diagnosis-Related Groups


Definition: An inpatient classification scheme that categorizes patients
who are medically related with respect to diagnosis and
treatment and who are statistically similar in their lengths of
stay from The International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM).

Suggested Data
Collection Question: What was the assigned diagnosis-related group for this
record?

Format: Length: 3
Type: Alphanumeric
Occurs: 1

Allowable Values: Any valid ICD-9-CM Diagnosis-Related Group code

Notes for Abstraction: None

• Face sheet
• UB-92

Inclusion Exclusion
None None



Data Element Name: Discharge Date


Definition: The month, day, and year the patient was discharged from
acute care, left against medical advice, or expired during this
stay.

Suggested Data
Collection Question: What is the date the patient was discharged from acute care,
left against medical advice (AMA), or expired?

Type: Date
Occurs: 1

DD = Day (01-31)

Notes for Abstraction: Because this data element is critical in determining the
population for many measures, the abstractor should NOT
assume that the claim information for the discharge date is
correct. If the abstractor determines through chart review
that the date is incorrect, she/he should correct and override
the downloaded value. If the abstractor is unable to
determine the correct discharge date through chart review,
she/he should default to the discharge date on the claim
information.

Suggested Data • Discharge summary
• Nursing discharge notes
• Physician orders
• Progress notes
• Transfer note

Inclusion Exclusion
None None



Data Element Name: Discharge Status


Definition: The place or setting to which the patient was discharged.

Suggested Data
Collection Question: What was the patient’s discharge disposition?

Format: Length: 2
Type: Alphanumeric
Occurs: 1

Allowable Values: 01 Discharged to home care or self care (routine discharge)
Usage Note: Includes discharge to home; jail or law
enforcement; home on oxygen if DMS only; any other
DMS only; group home, foster care, and other residential
care arrangements; outpatient programs, such as partial
hospitalization or outpatient chemical dependency
programs; assisted living facilities that are not state-
designated.

02 Discharged/transferred to a short term general hospital
for inpatient care

03 Discharged/transferred to skilled nursing facility (SNF)
with Medicare certification in anticipation of skilled care
Usage Note: Medicare-indicates that the patient is
discharged/transferred to a Medicare certified nursing facility.
For hospitals with an approved swing bed arrangement, use
Code 61-Swing Bed. For reporting other discharges/transfers
to nursing facilities, see 04 and 64.

04 Discharged/transferred to an intermediate care facility
(ICF)
Usage Note: Typically defined at the state level for specifically
designated intermediate care facilities. Also used to designate
patients that are discharged/transferred to a nursing facility
with neither Medicare nor Medicaid certification and for
discharges/transfers to state designated Assisted Living
Facilities.
05 Discharged/transferred to a designated cancer center or
children’s hospital
Usage Note: Transfers to non-designated cancer hospitals
should use Code 02. A list of (National Cancer Institute)
Designated Cancer Centes can be found at



Allowable Values HHTThttp://www3.cancer.gov/cancercenters/centerslist.htmlT
continued: THH

06 Discharged/transferred to home under care of organized
home health service organization in anticipation of
covered skilled care
Usage Note: Report this code when the patient is
discharged/transferred to home with a written plan of care
(tailored to the patient’s medical needs) for home care
services.

07 Left against medical advice or discontinued care

20 Expired

43 Discharged/transferred to a federal health care facility
Usage Note: Discharges and transfers to a government
operated health care facility such as a Department of
Defense hospital, a Veteran’s Administration hospital or a
Veteran’s Administration nursing facility. To be used
whenever the destination at discharge is a federal health
care facility, whether the patient resides there or not.

50 Hospice - home

51 Hospice - medical facility (certified) providing hospice
level of care

61 Discharged/transferred to hospital-based Medicare
approved swing bed
Usage Note: Medicare-used for reporting patients
discharged/ transferred to a SNF level of care within the
hospital's approved swing bed arrangement.

62 Discharged/transferred to an inpatient rehabilitation
facility (IRF) including rehabilitation distinct part units of
a hospital

63 Discharged/transferred to a Medicare certified long term
care hospital (LTCH)
Usage Note: For hospitals that meet the Medicare criteria for
LTCH certification.
Allowable Values 64 Discharged/transferred to a nursing facility certified
continued: under Medicaid but not certified under Medicare



65 Discharged/transferred to a psychiatric hospital or
psychiatric distinct part unit of a hospital

66 Discharged/transferred to a Critical Access Hospital
(CAH)

70 Discharged/transferred to another type of health care
institution not defined elsewhere in this code list (See
Code 05)

THE JOINT COMMISSION NOTE: If state assigned codes
are used, it is the measurement system’s responsibility to
crosswalk the code to one of the allowable values listed
above for the purposes of ORYXPP®PP.

Note:
CMS and The Joint Commission are aware that there are
additional UB-04 allowable values for this data element;
however, they are not used for the national quality measures
set at this time.

Notes for Abstraction: • The values for Discharge Status are taken from the
National Uniform Billing Committee (NUBC) manual
which is used by the billing/HIM to complete the UB-04.
• Because this data element is critical in determining the
population for many measures, the abstractor should
NOT assume that the UB-04 value is what is reflected in
the medical record. For abstraction purposes, it is
important that the medical record reflect the appropriate
discharge status. If the abstractor determines through
chart review that the claim information discharge status is
not what is reflected in the medical record, she/he should
correct and override the downloaded value.
• It would be appropriate to work with your billing office to
develop processes that can be incorporated to improve
medical record documentation to support the appropriate
discharge status and to ensure consistency between the
claim information discharge status and the medical
record.



Suggested Data • Discharge instruction sheet
Sources: • Discharge summary
• Face sheet
• Nursing discharge notes
• Progress notes
• Social service notes
• Transfer record

Inclusion Exclusion
Refer to Appendix H, Table 2.5 None
Discharge Status Disposition.



Data Element Name: Employed APNs


Definition: The total number of eligible advanced practice nurses
employed on the last day of a month.

Suggested Data
Collection Question: What was the total number of advance practice nurses
employed on the last day of the month?

Format: Length: 5
Type: Numeric
Occurs: 1


• When a unit is permanently closed the last reported rate
would be the last full month of service/care provided on
that unit.

• Human Resource employment records


Inclusion Exclusion
Full-time and part-time Advance practice Advance practice nurse (APN) per
nurses (APN) engaged in direct patient diems, contractors, consultants,
care positions or related nursing temporary agency, travelers, students
supervisory positions and positions for or other non-permanent employees
which an advanced (RN) nursing degree
is a specific condition of hire



Data Element Name: Employed LPN/LVNs


Definition: The total number of eligible Licensed Practical / Licensed
Vocational Nurses employed on the last day of the month.

Suggested Data
Collection Question: What was the total number of Licensed Practical and
Licensed Vocational Nurses employed on the last day of the
month?

Format: Length: 5
Type: Numeric
Occurs: 1


that unit.

• Human resource employment records


Inclusion Exclusion
Full-time and part-time Licensed Practical Licensed Practical Nurses (LPN) and
Nurses (LPN) and Licensed Vocational Licensed Vocational Nurses (LVN) per
Nurses (LVN) engaged in direct patient diems, contractors, consultants,
care positions. temporary agency, travelers, students
or other non-permanent employees.



Data Element Name: Employed RNs


Definition: The total number of eligible Registered Nurses employed on
the last day of the month.

Suggested Data
Collection Question: What was the total number of Registered Nurses employed
on the last day of the month?

Format: Length: 5
Type: Numeric
Occurs: 1


that unit.



Inclusion Exclusion
Full-time and part-time Registered Nurses Registered Nurse (RN) per diems,
(RN) engaged in direct patient care contractors, consultants, temporary
positions or related nursing supervisory agency, travelers, students or other
positions and positions for which an RN non-permanent employees.
nursing degree is a specific condition of
hire.



Data Element Name: Employed UAPs


Definition: The total number of eligible Unlicensed Assistive Personnel
(UAP) employed on the last day of the month.

Suggested Data
Collection Question: What was the total number of UAP employed on the last day
of the calendar month?

Format: Length: 5
Type: numeric
Occurs: 1


that unit.
• UAP are individuals trained to function in an assistive role
to nurses in the provision of patient care, as delegated by
and under the supervision of the registered nurse.
Typical activities performed by UAPs may include (but
are not limited to):
• Taking vital signs
• Bathing, feeding, or dressing patients
• Assisting patient with transfers, ambulation, or
toileting
• NOTE: In some states assistive nursing personnel may
be licensed. For the purposes of this performance
measure set, include these persons in the UAP category
for calculation.



Inclusion Exclusion
• Full-time and part-time UAP • Per diems, contractors, consultants,
engaged in direct patient care temporary agency, travelers or other non-
positions. permanent employees.
• Nursing assistants • Unit secretaries or clerks
• Orderlies • Monitor technicians



• Patient care • Therapy assistants
technicians/assistants • Student nurses who are fulfilling
• Graduate nurse (not yet educational requirements
licensed) who have completed • Sitters who either are not employed by the
unit orientation facility or who are employed by the facility,
but are not providing typical UAP activities



Data Element Name: Event Identifier


Definition: An identifier generated to uniquely identify this patient event.
It is a fictitious identifier used to differentiate between
individual events.

This identifier will not be derived from or related to
information about the patient in such a way that it is possible
to identify the patient via a review or manipulation of the
data.

Suggested Data
Collection Question: Not applicable, this data element is not data entered.

Format: Length: 9
Type: Numeric
Occurs: 1

Allowable Values: Any valid positive number


Suggested Data Does not apply, generated by the user or data
Sources: collection tool.

Inclusion Exclusion
None None



Data Element Name: Event Type


Definition: The measure-related event being identified.

Suggested Data
Collection Question: What is the identified measure-related outcome?

Format: Length: 1
Type: Alphanumeric
Occurs: 1

Allowable Values: 1 UTI – urinary tract infection
2 PNEU - pneumonia
3 BSI – bloodstream infection
4 No infection events this month
5 Fall
6 No falls this month

• Infection event must meet specific definitions (see
Appendix F)
• Infection event must also complete Date of Event, Device
and Specific Event Type
• Fall event must also complete Fall Injury Level

• Laboratory reports
• Nurses notes
• Progress notes
• Radiology reports

Inclusion Exclusion
See Appendix F None



Data Element Name: Fall Injury Level


Definition: The patient’s condition after 24 hours from the fall.

Suggested Data
Collection Question: What was the injury level experienced by this patient as a
result of this fall?

Format: Length: 1
Type: Alphanumeric
Occurs: 1

Allowable Values:
1 None - patient had no injuries
2 Minor - resulted in application of a dressing, ice, cleaning
of a wound, limb elevation, topical medication, bruise or
abrasion
3 Moderate - resulted in suturing, application of steri-
strips/skin glue, splinting, or muscle or joint strain
4 Major - resulted in surgery, casting, traction, fracture, or
required consultation for neurological or internal injury
5 Death - the patient died as a result of injuries sustained
from the fall
6 UTD – Unable to Determine from the documentation

• When the initial fall report is written by the nursing staff,
the extent of the injury may not yet be known. A method
to follow up on the patient’s condition after 24 hours from
the fall must be established.
• When the patient is discharged within 24 hours from the
fall determine injury level at the time of discharge.
• X-ray, CT scan or other radiological evaluation resulting
in a finding of no injury, with no treatment and no signs or
symptoms of injury- select “1 None”.
• Patients with coagulopathy who receive blood products
as a result of a fall - select “4 Major”.

• Incident, variance or occurrence report
• Nurses notes
• Progress notes
• Radiology report after time of fall



Inclusion Exclusion
None None



Data Element Name: Hospital Patient Identifier


Definition: The number used by the hospital to identify this patient’s
stay, e.g., Medical Record Number, Account Number,
Unique Identifiable Number as determined by the facility, etc.

Suggested Data
Collection Question: What was the number used by the hospital to identify this
patient’s stay?

Format: Length: 40
Type: Alphanumeric
Occurs: 1

Allowable Values: Up to 40 letters and/or numbers


Suggested Data None
Sources:

Inclusion Exclusion
None None



Data Element Name: ICD-9-CM Other Diagnosis Codes


Definition: The International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) codes associated with the
diagnosis for this hospitalization.

Suggested Data
Collection Question: What were the ICD-9-CM other diagnosis codes selected for
this medical record?

Format: Length: 6 (with or without decimal point)
Type: Alphanumeric
Occurs: 17

Allowable Values: Any valid ICD-9-CM diagnosis code


• UB-04, Field Locations: 67A-Q
Note:
Medicare will only accept codes listed in fields A-H

Inclusion Exclusion
None None



Data Element Name: ICD-9-CM Other Procedure Codes


Clinical Modification (ICD-9-CM) codes identifying all
significant procedures other than the principal procedure.

Suggested Data
Collection Question: What were the ICD-9-CM code(s) selected as other
procedure(s) for this record?

Type: Alphanumeric
Occurs: 5

Allowable Values: Any valid ICD-9-CM procedure code


• UB-04, Field Location: 74A-E

Inclusion Exclusion
None None



Data Element Name: ICD-9-CM Other Procedure Dates


Definition: The month, day, and year when the associated procedure(s)
was (were) performed.

Suggested Data
Collection Question: What were the date(s) the other procedure(s) were
performed?

Format: Length: 10 – MM-DD-YYYY (includes dashes) or UTD
Type: Date
Occurs: 5

DD = Day (01-31)

Notes for Abstraction: • If the procedure date for the associated procedure is
unable to be determined from medical record
documentation, enter UTD.
(taken at “face value”). When the date documented is
obviously in error (not a valid format/range or outside of
the parameters of care [after Discharge Date]) and no
other documentation is found that provides this
information, the abstractor should select “UTD.”
Examples:
o Documentation indicates the ICD-9-CM Other
Procedure Dates was 02-42-2008. No other
documentation in the medical record provides a valid
date. Since the ICD-9-CM Other Procedure Dates is
outside of the range listed in the Allowable Values for
“Day,” it is not a valid date and the abstractor should
select “UTD.”
o Patient expires on 02-12-2008 and documentation
indicates the ICD-9-CM Other Procedure Dates was
03-12-2008. Other documentation in the medical
record supports the date of death as being accurate.
Since the ICD-9-CM Other Procedure Dates is after
the Discharge Date (death), it is outside of the
parameters of care and the abstractor should select
“UTD.”



Notes for Abstraction Note:
continued: Transmission of a case with an invalid date as described
above will be rejected from the QIO Clinical Warehouse
and the Joint Commission’s Data Warehouse. Use of
“UTD” for ICD-9-CM Other Procedure Dates allows the

Suggested Data • Consultation notes
Sources: • Diagnostic test reports
• Discharge summary
• Face sheet
• Operative notes
• Procedure notes
• Progress notes
• UB-04, Field Location: 74A-E

Inclusion Exclusion
None None



Data Element Name: ICD-9-CM Principal Diagnosis Code


Clinical Modification (ICD-9-CM) code associated with the
diagnosis established after study to be chiefly responsible for
occasioning the admission of the patient for this
hospitalization.

Suggested Data
Collection Question: What was the ICD-9-CM code selected as the principal
diagnosis for this record?

Type: Alphanumeric
Occurs: 1

Allowable Values: Any valid ICD-9-CM diagnosis code

Notes for Abstraction: 195B195BThe principal diagnosis is defined in the Uniform
Hospital Discharge Data Set (UHDDS) as “that condition
established after study to be chiefly responsible for
occasioning the admission of the patient to the hospital for
care.”


Inclusion Exclusion
None None



Data Element Name: ICD-9-CM Principal Procedure Code


Clinical Modification (ICD-9-CM) code that identifies the
principal procedure performed during this hospitalization.
The principal procedure is the procedure performed for
definitive treatment rather than diagnostic or exploratory
purposes, or which is necessary to take care of a
complication.

Suggested Data
Collection Question: What was the ICD-9-CM code selected as the principal
procedure for this record?

Type: Alphanumeric
Occurs: 1

Allowable Values: Any valid ICD-9-CM procedure code

Notes for Abstraction: The principal procedure as described by the Uniform
Hospital Discharge Data Set (UHDDS) is one performed for
definitive treatment rather than diagnostic or exploratory
purposes, or which is necessary to take care of a
complication.


Inclusion Exclusion
None None



Data Element Name: ICD-9-CM Principal Procedure Date


Definition: The month, day, and year when the principal procedure was
performed.

Suggested Data
Collection Question: What was the date the principal procedure was performed?

Format: Length: 10 – MM-DD-YYYY (includes dashes) or UTD
Type: Date
Occurs: 1

DD = Day (01-31)

Notes for Abstraction: • 201B201BIf the principal procedure date is unable to be
determined from medical record documentation, enter
UTD.
(taken at “face value”). When the date documented is
obviously in error (not a valid date/format or is outside of
the parameters of care [after Discharge Date]) and no
other documentation is found that provides this information,
the abstractor should select “UTD.”
Examples:
o Documentation indicates the ICD-9-CM Principal
Procedure Date was 02-42-2008. No other
documentation in the medical record provides a valid
date. Since the ICD-9-CM Principal Procedure Date is
outside of the range listed in the Allowable Values for
“Day,” it is not a valid date and the abstractor should
select “UTD.”
o Patient expires on 02-12-2008 and documentation
indicates the ICD-9-CM Principal Procedure Date was
03-12-2008. Other documentation in the medical
record supports the date of death as being accurate.
Since the ICD-9-CM Principal Procedure Date is after
the Discharge Date (death), it is outside of the
parameter of care and the abstractor should select
“UTD.”



Notes for Abstraction
continued: Note:
Transmission of a case with an invalid date as described
above will be rejected from the QIO Clinical Warehouse
and the Joint Commission’s Data Warehouse. Use of
“UTD” for ICD-9-CM Principal Procedure Date allows the

Sources: • Diagnostic test reports
• Discharge summary
• Face sheet
• Operative notes
• Procedure notes
• Progress notes

Inclusion Exclusion
None None



Data Element Name: Indwelling Urinary Catheter Days


Definition: Any day that a patient has an indwelling urinary catheter
device in place at the time the count is done. This daily count
is aggregated/ summed across the days of the month to
provide the total number of urinary catheter days for the
month for each individual ICU Location.

Suggested Data
Collection Question: What is the total number of indwelling urinary catheter days
for this ICU Location for the month?

Format: Length: 5
Type: Numeric
each report stratum)


Notes for Abstraction: Indwelling urinary catheter days should be counted in a
consistent manner (e.g., at the same time each day). A
separate catheter day count is collected for each ICU
location.

• Graphic sheets
• Nurses notes
• Progress notes

Inclusion Exclusion
None Do not count straight in –and-out
catheters or catheters not inserted into
the urinary bladder through the urethra



Data Element Name: Location


Definition: The patient’s location for collection of device days of interest
(e.g., central line, umbilical catheter, urinary catheter,
ventilator).

Suggested Data
Collection Question: What is the ICU location for the device days collected for the
month?

Format: Length: 9
Type: Alphanumeric
Occurs: 1

Allowable Values: Code for ICU Location

B-Adult Burn Critical Care – Adult
MC-Adult Medical Cardiac Critical Care - Adult
SCT-Adult Surgical Cardiothoracic Critical Care-Adult
M-Adult Medical Critical Care – Adult
MS1-Adult Combined medical/surgical Critical Care - Adult
(major teaching hospital)
(all hospitals other than major teaching)
N-Adult Neurologic Critical Care - Adult
NS-Adult Neurosurgical Critical Care – Adult
R-Adult Respiratory Critical Care – Adult
S-Adult Surgical Critical Care – Adult
T-Adult Trauma Critical Care – Adult

B-Ped Burn Critical Care – Pediatric
CT-Ped Cardiothoracic Critical Care- Pediatric
M-Ped Medical Critical Care – Pediatric
MS-Ped Medical-Surgical Critical Care - Pediatric
NS-Ped Neurosurgical Critical Care - Pediatric
R-Ped Respiratory Critical Care - Pediatric
S-Ped Surgical Critical Care - Pediatric
T-Ped Trauma Critical Care - Pediatric

N-III Neonatal Intensive Care Unit (NICU) – Level III
N-II-III Neonatal Intensive Care Unit (NICU) –
Combined Level II - III



• To select the unit types first determine the acuity level of the
patients typically served on the unit. If the unit has 90% or
greater of the same acuity type, select that acuity level. If the
unit acuity level does not meet the criteria of 90% or greater
for one acuity level type, then select mixed acuity unit. For
example, if 90% or greater of the patients typically served on
the unit require the highest level of care select critical care
unit; if the unit has 30% step-down or intermediate level of
care and 70% med-surg patients select mixed acuity unit; if
the level of acuity is med/surg, and the unit typically serves
90% or greater surgical patients select surgical unit type; if
the unit acuity level is med/surg and serves 60% medical
and 40% surgical, select med-surg combined unit.
• To select a specialty unit or location type the patients served
must be 80% or greater of the same specialty type to select
the specialty or location type. For example if 80% of the
patients served are cardiac surgery select surgical
cardiothoracic critical care. For NSC 6, 7, and 8 when
selecting the Location or Location of Attribution data element
and the unit does not meet the criteria of 80% of one
specialty type, the location should be mapped to the CDC
Location equivalent specialty type.

• Diagnostic codes
• Graphic sheets
• Nurses notes
• Physician progress notes
• Progress notes

Inclusion Exclusion
None None



Data Element Name: Location of Attribution


Definition: The location to which the event being measured is assigned
to.

Suggested Data
Collection Question: To what location is the infection event attributed?

Format: Length: 9
Type: Alphanumeric
Occurs: 1

Allowable Values:
Code for ICU Location of Attribution

B-Adult Burn Critical Care – Adult
MC-Adult Medical Cardiac Critical Care - Adult
SCT-Adult Surgical Cardiothoracic Critical Care-Adult
M-Adult Medical Critical Care – Adult
(major teaching hospital)
(all hospitals other than major teaching)
N-Adult Neurologic Critical Care - Adult
NS-Adult Neurosurgical Critical Care – Adult
R-Adult Respiratory Critical Care – Adult
S-Adult Surgical Critical Care – Adult
T-Adult Trauma Critical Care – Adult

B-Ped Burn Critical Care – Pediatric
CT-Ped Cardiothoracic Critical Care- Pediatric
M-Ped Medical Critical Care – Pediatric
MS-Ped Medical-Surgical Critical Care - Pediatric
NS-Ped Neurosurgical Critical Care - Pediatric
R-Ped Respiratory Critical Care - Pediatric
S-Ped Surgical Critical Care - Pediatric
T-Ped Trauma Critical Care - Pediatric

N-III Neonatal Intensive Care Unit (NICU) – Level III
N-II-III Neonatal Intensive Care Unit (NICU) –
Combined Level II -III



• If the infection develops in a patient within 48 hours of
discharge from the ICU/NICU location, attribute to the
discharging location, not the current location of the patient.

• Diagnostic codes
• Graphic sheets
• Nurses notes
• Physician progress notes
• Progress notes

Inclusion Exclusion
None None



Data Element Name: LPN/LVN Hours [Contract/Agency]

Collected For: NSC 9.1, 9.2, 9.3, 9.4, 10.2

Definition: Total number of productive hours worked by Licensed
Practical Nurses and Licensed Vocational Nurses contracted
to the facility with direct patient care responsibilities.

Suggested Data
Collection Question: What was the total number of productive hours worked by
Licensed Practical Nurses and Licensed Vocational Nurses
with patient care responsibilities contracted to the facility
during the calendar month?

Format: Length: 5
Type: Alphanumeric
Occurs: 1 - Overall
1 per strata


• Check to be sure that contract/agency hours are included
by licensure category.
• Negative numbers are not allowed
• Outliers should be checked during data cleaning
• Productive Hours are actual direct hours worked, not
budgeted or scheduled hours and excludes vacation, sick
time, orientation, education leave, or committee time.

• Patient Acuity System
• Payroll Accounting
• Staffing System
• Other (or combination of two of the above)

Inclusion Exclusion
None None



Data Element Name: LPN/LVN Hours [Employee]

Collected For: NSC 9.1, 9.2, 9.3, 9.4, 10.2

Definition: Total number of productive hours worked by Licensed
Practical Nurses and Licensed Vocational Nurses with direct
patient care responsibilities, who are replaced if they call in
sick and are employed directly by the facility.

Suggested Data
Collection Question: What was the total number of productive hours worked by
Licensed Practical Nurses and Licensed Vocational Nurses
with direct patient care responsibilities, who are replaced if
they call in sick and are employed directly by the facility
during the calendar month?

Format: Length: 5
Type: Alphanumeric
Occurs: 1 Overall
1 per strata


• Check to be sure that contract/agency hours are included
by licensure category.
• Outliers should be checked during data cleaning

Suggested Data Sources: Sources for reporting nursing hours include:
• Staffing System

Inclusion Exclusion
None None



Data Element Name: Major Diagnostic Category (MDC)


Definition: This initial broad classification of diagnoses, typically
grouped by body system, to which a patient is assigned
when determining a DRG within The International
Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM) classification system.

Suggested Data
Collection Question: What was the assigned Major Diagnostic Category for this
record?

Format: Length: 2
Type: Numeric
Occurs: 1

Allowable Values: Any valid ICD-9-CM MDC code


• Face sheet
• UB-92, Other

Inclusion Exclusion
None None



Data Element Name: Month

Collected For: NSC 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2, 9.1, 9.2, 9.3, 9.4, 10.1,
10.2, 11.1, 11.2, 11.3

Definition: The 2 digit month during which the measure specific episode
occurred.

Suggested Data
Collection Question: What was the month during which the measure specific
episode occurred?

Format: Length: 2
Type: Alphanumeric
Occurs: 1
Allowable Values:
01 January 05 May 09 September
02 February 06 June 10 October
03 March 07 July 11 November
04 April 08 August 12 December


• Measure specific data collection documentation
(electronic or manual)

Inclusion Exclusion
None None



Data Element Name: Number of Patient Falls


Definition: The total number of patient falls that occurred on the eligible
reporting unit during the calendar month.

Suggested Data
Collection Question: What was the total number of patient falls for this unit during
the calendar month?

Format: Length: 4
Type: Numeric
Occurs: 1

Allowable Values: 0-9999

• Enter 0 if no falls occurred; or Event Type 6 ”No falls this
month”.
• It is recommended that your facility outline internal data
and staff sources that will be used to report on this
measure and to be sure your data conform to measure
specifications.
• Any event related to a patient fall that occurs on an
eligible reporting unit and generates a report should be
counted.

• Secondary risk management sources
• Incident Reports
• Variance Reports
• Event Reports

Inclusion Exclusion
None None



Data Element Name: Number of Responses


Definition: The number of responses for the survey question.

Suggested Data
Collection Question: What was the total number of responses for this question?

Format: Length: 5
Type: Numeric
Occurs: 31



• The Practice Environment Scale of the Nursing Work
Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: Observed Pressure Ulcer – Hospital-Acquired


Definition: Documentation that the observed pressure ulcer meets the
criteria for hospital-acquired (nosocomial).
Hospital-acquired ulcers are those discovered or
documented after the first 24 hours from the time of inpatient
admission.

Suggested Data
Collection Question: Was the pressure ulcer discovered or documented after the
first 24 hours from the time of inpatient admission?

Format: Length: 1
Type: Alphanumeric
Occurs: 48

Allowable Values:
1 (Yes) Pressure Ulcer was discovered or documented
after the first 24 hours from the time of inpatient
admission
2 (No) Pressure Ulcer was discovered or documented
within the first 24 hours from the time of inpatient
admission
3 (UTD) Unable to Determine from the documentation

• A community acquired pressure ulcer is defined by: Ulcer
discovered/documented within the first 24 hours from the
time of inpatient admission; or Prevalence study was
done within the first 24 hours from the time of inpatient
admission and ulcer was already present
• Hospital-acquired pressure ulcers refer to new ulcer(s)
developed after the first 24 hours from the time of
inpatient admission. All pressure ulcers not meeting the
community-acquired criteria should be designated as
hospital-acquired pressure ulcers.
• An ulcer of category/stage II or greater observed after the
first 24 hours from the time of inpatient admission AND
for which there is no documentation in the record
indicating the date of first discovery; should be
considered as hospital-acquired.
• This data element is completed for each documented
pressure ulcer.



• Nurses notes
• Pressure ulcer prevalence study worksheet or data
collection tool
• Progress notes

Inclusion Exclusion
None None



Data Element Name: Observed Pressure Ulcer - Category/stage


Definition: Documentation of the category/stage for the observed
pressure ulcer using the NPUAP / EPUAP Pressure Ulcer
Classification System.

Suggested Data
Collection Question: What was the category/stage for this pressure ulcer?

Format: Length: 1
Type: Alphanumeric
Occurs: 48

Allowable Values:
1 Category/stage I - Non-blanchable erythema
2 Category/stage II– Partial thickness
3 Category/stage III– Full thickness skin loss
4 Category/stage IV– Full thickness tissue loss
5 Unstageable/ Unclassified– Full thickness skin or tissue
loss – depth unknown
6 Suspected deep tissue injury– depth unknown
7 There is no documentation of category/stage or Unable
to Determine from the documentation

• Follow NPUAP / EPUAP Pressure Ulcer Classification
System. (see Appendix D, Table 1)
• This data element is completed for each documented
pressure ulcer.

• Nurses notes
collection tool
• Progress notes

Inclusion Exclusion
None None



Data Element Name: Observed Pressure Ulcer(s)


Definition: Documentation that a pressure ulcer was or was not
observed at the time of the prevalence study.

Suggested Data
Collection Question: How many pressure ulcers were observed on the day of the
prevalence study?

Format: Length: 1
Type: Alphanumeric
Occurs: 48

Allowable Values: 0-48

• Follow the Prevalence Study Methodology in Appendix
E.
• Skin breakdown due to arterial occlusion, venous
insufficiency, diabetes related neuropathy, or
incontinence dermatitis are not pressure ulcers.
• No value should be recorded more than once.
• All observed pressure ulcers should be documented
following prevalence study definitions.

collection tool

Inclusion Exclusion
All patients on all eligible units present at • Patients who refuse to be assessed
the time the study is conducted. • Patients who are off the unit at the
time of the prevalence study, i.e.
surgery, x-ray, physical therapy, etc.
• Patients who are medically unstable
at the time of the study for whom
assessment would be contraindicated
at the time of the study, i.e. unstable
blood pressure, uncontrolled pain, or
fracture waiting repair.
• Patients who are actively dying and
pressure ulcer prevention is no longer
a treatment goal.



Data Element Name: Patient Days

Collected For: NSC 4, 5, 10.1, 10.2

Definition: The total number of patient days, per unit, for a month.

Suggested Data
Collection Question: What is the total number of patient days for this unit during
the calendar month?

Format: Length: 5
Type: Numeric
Occurs: 1


Notes for Abstraction: Hospital selects one method to determine patient days, as
appropriate to their patient population and as supported by
their information resources. See Appendix D, Patient Days
Reporting Methods.

• Accounting or billing systems
• Admission/discharge/transfer systems
• Actual patient hours, short and long stay
• Actual short stay patient hours
• Multiple daily census reports
• Patient census records, including: Midnight census

Inclusion Exclusion
See Appendix D, Patient Days Reporting A negative number
Methods



Data Element Name: Payment Source


Definition: The source of payment for this episode of care.

Suggested Data
Collection Question: What is the patient’s source of payment for this episode of
care?

Format: Length: 1
Type: Alphanumeric
Occurs: 1

Allowable Values: 1 Source of payment is Medicare.

2 Source of payment is Non-Medicare.

Notes for Abstraction: • If Medicare is listed as the primary, secondary, tertiary, or
even lower down on the list or payers, select “1”.
• If the patient is an Undocumented Alien or Illegal
immigrant, select “1.” Undocumented Alien: Section
1011 of the Medicare Modernization Act of 2003 allows
for reimbursement for services rendered to patients who
are: Undocumented or illegal aliens (immigrants), Aliens
who have been paroled into a United States port of entry
and Mexican citizens permitted to enter the United States
on a laser visa.

Suggested Data • Face sheet
Sources: • UB-04, Field Location: 50A, B or C

Inclusion Exclusion
Medicare includes, but is not limited to: None
• Medicare Fee for Service (includes
DRG or PPS)
• Black Lung
• End Category/stage Renal Disease
(ESRD)
• Railroad Retirement Board (RRB)
• Medicare Secondary Payer
• Medicare HMO/Medicare Advantage



Data Element Name: PES-NWI Adequate Support Services


Definition: Adequate support services allow me to spend time with my
patients.

Suggested Data
Collection Question: Adequate support services allow me to spend time with my
patients.

Format: Length: 1
Type: Numeric
Occurs: 1

Allowable Values: 4 Strongly Agree
3 Agree
2 Disagree
1 Strongly Disagree
0 No Response or Unable to Determine

• Data is abstracted from individual survey responses.
• If the respondent did not mark an answer or you are not
able to determine which single answer was marked,
select “0 No Response or Unable to Determine” The “0”
selection is for analysis purposes only and is not a
selection option listed on the survey tool.

Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Administration Listens and Responds


Definition: Administration that listens and responds to employee
concerns.

Suggested Data
Collection Question: Administration that listens and responds to employee
concerns.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Advancement Opportunities


Definition: Opportunity for advancement is available in your current job.

Suggested Data
Collection Question: Opportunities for advancement.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI))

Inclusion Exclusion
None None



Data Element Name: PES-NWI Career Development


Definition: Career development/clinical ladder opportunity exists in your
present job.

Suggested Data
Collection Question: Career development/clinical ladder opportunity.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Chief Nursing Officer Authority


Definition: The chief nurse officer is equal in power and authority to
other top-level hospital executives.

Suggested Data
Collection Question: A chief nurse office equal in power and authority to other
top-level hospital executives.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Chief Nursing Officer Visibility


Definition: A chief nursing officer who is highly visible and accessible to
staff.
Suggested Data
Collection Question: A chief nursing officer who is highly visible and accessible to
staff.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Collaboration


Definition: Collaboration (joint practice) between nurses and physicians
is present in your current job.

Suggested Data
Collection Question: Collaboration (joint practice) between nurses and physicians.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Continuing Education


Definition: Active staff development or continuing education programs
for nurses exist in your current job.

Suggested Data
Collection Question: Active staff development or continuing education programs
for nurses.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Continuity of Patient Assignments


Definition: Patient care assignments that foster continuity of care, i.e.
the same nurse cares for the patient from one day to the
next are used in your current job.

Suggested Data
Collection Question: Patient care assignments that foster continuity of care, i.e.
the same nurse cares for the patient from one day to the
next.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Enough Nurses for Quality Care


Definition: There are enough registered nurses to provide quality
patient care.

Suggested Data
Collection Question: Enough registered nurses to provide quality patient care.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Enough Staffing


Definition: Enough staff to get the work done.

Suggested Data
Collection Question: Enough staff to get the work done.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI High Nursing Care Standards


Definition: High standards of nursing care are expected by the
administration.

Suggested Data
Collection Question: High standards of nursing care are expected by the
administration.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Nurse and Physician Relationships


Definition: Physicians and nurses have good working relationships at
your current job

Suggested Data
Collection Question: Physicians and nurses have good working relationships.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Nurse and Physician Teamwork


Definition: A lot of teamwork between nurses and physicians is present
in your current job.

Suggested Data
Collection Question: A lot of teamwork between nurses and physicians.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Nurse Manager and Leader


Definition: A nurse manager who is a good manager and leader is
present in your current job.

Suggested Data
Collection Question: A nurse manager who is a good manager and leader.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Nurse Manager Backs up Staff


Definition: A nurse manager who backs up the nursing staff in decision
making even if the conflict is with a physician is present in
your current job.

Suggested Data
Collection Question: A nurse manager who backs up the nursing staff in decision
making even if the conflict is with a physician.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Nurses Are Competent


Definition: Working with nurses who are clinically competent.

Suggested Data
Collection Question: Working with nurses who are clinically competent.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Nursing Administrators Consult


Definition: Nursing administrators consult with staff on daily problems
and procedures.

Suggested Data
Collection Question: Nursing administrators consult with staff on daily problems
and procedures.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Nursing Care Model


Definition: Nursing care is based on a nursing, rather than a medical,
model.

Suggested Data
Collection Question: Nursing care is based on a nursing, rather than a
medical, model.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Nursing Committees


Definition: Staff nurses have the opportunity to serve on hospital and
nursing committees.

Suggested Data
Collection Question: Staff nurses have the opportunity to serve on hospital and
nursing committees.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Nursing Diagnosis


Definition: Nursing diagnosis is used in your current job.

Suggested Data
Collection Question: Use of nursing diagnosis.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Participation in Policy Decisions


Definition: Opportunity for staff nurses to participate in policy decisions
is present in your current job.

Suggested Data
Collection Question: Opportunity for staff nurses to participate in policy decisions

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Patient Care Plans


Definition: Written, up-to-date nursing care plans for all patients are
present in your current job.

Suggested Data
Collection Question: Written, up-to-date nursing care plans for all patients

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Philosophy of Nursing


Definition: A clear philosophy of nursing that pervades the patient care
environment is present in your current job.

Suggested Data
Collection Question: A clear philosophy of nursing that pervades the patient care
environment.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Preceptor Program


Definition: A preceptor program for newly hired RNs is present in your
current job.

Suggested Data
Collection Question: A preceptor program for newly hired RNs.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Quality Assurance Program


Definition: An active quality assurance program is present in your
current job.

Suggested Data
Collection Question: An active quality assurance program.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Recognition


Definition: Praise and recognition for a job well done are present in your
current job.

Suggested Data
Collection Question: Praise and recognition for a job well done.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Staff Nurses Hospital Governance


Definition: Staff nurses are involved in the internal governance of the
hospital (e.g., practice and policy committees) in your current job.

Suggested Data
Collection Question: Staff nurses are involved in the internal governance of the
hospital (e.g., practice and policy committees).

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Supervisors Learning Experiences


Definition: Supervisors use mistakes as learning opportunities, not
criticism in your current job.

Suggested Data
Collection Question: Supervisors use mistakes as learning opportunities, not
criticism

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Supportive Supervisory Staff


Definition: A supervisory staff that is supportive of the nurses is present
in your current job.

Suggested Data
Collection Question: A supervisory staff that is supportive of the nurses.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: PES-NWI Time to Discuss Patient Problems


Definition: There is enough time and opportunity to discuss patient care
problems with other nurses in your current job.

Suggested Data
Collection Question: Enough time and opportunity to discuss patient care
problems with other nurses.

Format: Length: 1
Type: Alphanumeric
Occurs: 1

3 Agree
2 Disagree
1 Strongly Disagree


Index (PES-NWI)

Inclusion Exclusion
None None



Data Element Name: Physical Restraint


Definition: Physical restraint (e.g., limb, waist, roll belt, vest, or side
rails) is any manual method, physical or mechanical device,
material, or equipment that immobilizes or reduces the ability
of a patient to move his or her arms, legs, body or head
freely.

Suggested Data
Collection Question: Was a physical restraint in place for this patient at the time
the prevalence study?

Format: Length: 1
Type: Alphanumeric
Occurs: 1

Allowable Values: 1 Physical restraints were in use
2 No physical restraints were in use
3 There is no documentation of physical restraints or
Unable to Determine from the documentation

• This data element is required for rate calculation
• Must also complete Type of Restraint

collection tool
• Nurses notes
• Progress notes
• Graphic sheets
• Patient Observation Worksheet




Inclusion Exclusion
Any manual method, physical or A restraint does not include devices,
mechanical device, material, or equipment such as orthopedically prescribed
that immobilizes or reduces the ability of a devices, surgical dressings or
patient to move his or her arms, legs, bandages, protective helmets, or other
body or head freely. For example: methods that involve the physical
• Tucking a patient’s sheets in so tightly holding of a patient for the purpose of
that the patient cannot move conduction routine physical
• Use of a “net bed” or an “enclosed examinations or tests, or to protect the
bed” that prevents the patient from patient from falling out of bed, or to
freely exiting the bed. (except permit the patient to participate in
placement of a toddler in an activities without the risk of physical
“enclosed” or “domed” crib) harm. For example:
• Use of “Freedom” splints that • Use of an IV arm board to stabilize
immobilize a patient’s limb an IV line is generally not
• Using side rails to prevent a patient considered a restraint. However, if
from voluntarily getting out of bed the arm board is tied down (or
• Geri chairs or recliners, only if the otherwise attached to the bed), the
patient cannot easily remove the use of the arm board would be
restraint appliance and get out of the considered a restraint.
chair on his or her own • A mechanical support used to
Note: Generally, if a patient can easily achieve proper body position,
remove a device, the device would not be balance, or alignment so as to allow
considered a restraint. In this context greater freedom of mobility that
“easily remove” means that the manual would be possible without the use
method, device , material, or equipment of such a support, i.e. leg braces for
can be removed intentionally by the walking, neck, head or back braces
patient in the same manner as it was to sit upright.
applied by the staff (e.g., side rails are put • Hand mitts when NOT pinned or
down, not climbed over: buckles are otherwise attached to bedding or
intentionally unbuckled; ties or knots are used in conjunction with a wrist
intentionally untied; etc.) considering the restraint.
patient’s physical condition and ability to
accomplish objective (e.g., transfer to a
chair, get to the bathroom in time).
CMS Hospital Conditions of Participations: Interpretive Guidelines available at
http://www.cms.hhs.gov accessed February 2009



Data Element Name: Point of Origin for Admission or Visit


Definition: A code indicating the point of patient origin for this
admission.

Suggested Data
Collection Question: What was the point of origin for this admission?

Format: Length: 1
Type: Alphanumeric
Occurs: 1

Allowable Values: 1 Non-Health Care Facility Point of Origin
The patient was admitted to this facility upon order of a
physician.
Usage Note: Includes patients coming from home, a
physician’s office, or workplace

2 Clinic
The patient was admitted to this facility as a transfer from
a freestanding or non-freestanding clinic.

3 Reserved for assignment by the NUBC
(Discontinued effective 10/1/2007.)

4 Transfer From a Hospital (Different Facility)
The patient was admitted to this facility as a hospital
transfer from an acute care facility where he or she was
an inpatient or outpatient.
Usage Note: Excludes Transfers from Hospital Inpatient
in the Same Facility (See Code D).

5 Transfer from a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF)
a SNF or ICF where he or she was a resident.

6 Transfer from another Health Care Facility
another type of health care facility not defined elsewhere
in this code list.
7 Emergency Room
The patient was admitted to this facility after receiving



Allowable Values services in this facility’s emergency room.
continued: Usage Note: Excludes patients who came to the
emergency room from another health care facility.

8 Court/Law Enforcement
The patient was admitted to this facility upon the direction
of court of law, or upon the request of a law enforcement
agency.
Usage Note: Includes transfers from incarceration
facilities.

9 Information not Available
The means by which the patient was admitted to this
hospital is unknown.

A Reserved for assignment by the NUBC.
(Discontinued effective 10/1/2007.)

D Transfer from One Distinct Unit of the Hospital to
another Distinct Unit of the Same Hospital Resulting
in a Separate Claim to the Payer
hospital inpatient within this hospital resulting in a
separate claim to the payer.
Usage Note: For purposes of this code, “Distinct Unit” is
defined as a unique unit or level of care at the hospital
requiring the issuance of a separate claim to the payer.
Examples could include observation services, psychiatric
units, rehabilitation units, a unit in a critical access
hospital, or a swing bed located in an acute hospital.

E Transfer from Ambulatory Surgery Center
an ambulatory surgery center.

F Transfer from Hospice and is Under a Hospice Plan of
Care or Enrolled in a Hospice Program
hospice.

Code Structure for Newborn (Used For PR-2 Only)

1 – 4 Reserved for assignment by the NUBC.
(Discontinued effective 10/1/2007)

5 Born Inside the Hospital



Allowable Values A baby born inside this Hospital
continued: 6 Born Outside this Hospital
A baby born outside this Hospital

Note:
CMS and The Joint Commission are aware that there are
additional UB-04 allowable values for this data element;
however, they are not used for the national quality measure
sets at this time.

Notes for Abstraction: • The intent of this data element is to focus on patients’
place or point of origin rather than the source of a
physician order or referral.
• The point of origin is the direct source for the particular
facility.
Example 1:
A SNF patient has chest pain is taken to the emergency
department of Hospital A where it is determined that she
is suffering an acute myocardial infarction. The patient is
then transferred to Hospital B for admission as an
inpatient. The Point of Origin for Hospital A would be 5 –
Transfer from a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF); the point of origin code
for Hospital b would be 4 – Transfer from a Hospital.
Example 2:
An auto accident victim was taken to the emergency
department of Hospital A by EMTs, stabilized, then
transferred to Hospital B where he receives additional
treatment in the ED, and then is admitted as an inpatient
to Hospital B. The Point of Origin code for Hospital A is
7 – Emergency Room; the point of origin for Hospital B
would be 4 – Transfer from a Hospital.
• The emergency room code is limited to patients who
receive unscheduled emergency services in the ER not
originating from another health care facility. As in the
auto accident example above, a victim brought to the
ER would be coded as 7 since the patient was not
previously at any other kind of health care facility. Code
7 also includes self-referrals in emergency situations
that require immediate medical attention.

Usage Notes/Cases:

I. Transfers – From an Another Facility
Overall Scenario
While at another acute care hospital/facility, the patient is



Notes for Abstraction seen by the emergency room physicians. The patient is
continued: then transferred to our facility through the emergency
room.
• The Point of Origin code would be Code 4 – Transfer
from a Hospital (Different Facility) due to the patient
being seen at the other acute care facility’s emergency
room.
• If the decision to admit was not made by the other
facility’s emergency room personnel and instead was
made by our facilities emergency room doctor, the
Point of Origin code would still be 4. Even though the
decision to admit was not made by the other facility,
the patient was still seen by the other facility’s
emergency room personnel and a decision to transfer
was made by them.
• The patient is seen by the other facility’s emergency
room physician; the patient arrives at our emergency
room, but receives no additional emergency room care
at our facility. Instead, the patient is transferred
immediately to the Heart Catheterization Department
of our facility, the Point of Origin code would still be 4.
Since the patient is seen by a different hospital’s
emergency room personnel, the decision to transfer
the patient is first made by the other facility. The
arrival of the patient at the receiving hospital’s
emergency room and subsequent transfer to the Heart
Catheterization Department is secondary to the
transfer from the previous facility transfer.

II. Transfers – Skilled Nursing Facility
Overall Scenario
A resident from a skilled nursing facility is taken to an
acute care hospital for medical care.
• The Point of Origin code would be Code 5 – Transfer
from a Skilled Nursing Facility.
• The patient’s family stopped by to pick-up the patient
for a routine doctor’s office visit (regularly
scheduled); but while at the doctor’s office the doctor
sends the patient to the emergency room of the
acute care hospital. The Point of Origin code would
be 5 as the original Point of Origin is the skilled
nursing facility. The subsequent visit to the doctor’s
office (or even the emergency room of the hospital)
is secondary to the events that took place earlier that
day.



Notes for Abstraction III. Transfer by Law Enforcement or Court
continued: Overall scenario
A patient arrives at the health care facility accompanied
by police.
• The Point of Origin code would be Code 8 –
Court/Law Enforcement as the patient is under the
supervision of law enforcement.

• If the patient was simply transported by law enforcement
to our facility, the patient is neither under arrest nor
serving any jail time, then the Point of Origin code would
be 7 – Emergency Room. Law enforcement is simply
transporting the patient for emergency/urgent care
treatment. The patient is not incarcerated (that is,
neither under arrest nor serving any jail time).

• Nursing admission notes
• Progress notes

Inclusion Exclusion
None None



Data Element Name: Prevalence Study Date

Collected For: NSC 2, 3

Definition: The date of the prevalence study

Suggested Data
Collection Question: On what date was the prevalence study conducted?

Type: Date
Occurs: 1

DD = Day (01-31)


• Pressure ulcer / restraint prevalence study worksheet or
data collection tool

Inclusion Exclusion
None None



Data Element Name: Reason for Separation

Collected For: NSC-11.1, 11.2, 11.3

Definition: The reason for employment separation.

Suggested Data
Collection Question: What was the reason the employee separated employment
from the hospital?

Format: Length: 2
Type: Numeric
Occurs: 1

Allowable Values:
1 Cutbacks due to mergers
2 Cyclical layoffs
3 Death
4 Disability
5 Did not return after leave of absence
6 Dissatisfied with compensation
7 Dissatisfied with management
8 Dissatisfied with team members
9 Dissatisfied with work environment
10 Dissatisfied with work schedule
11 Education / return to school
12 Illness
13 Military service
14 Other permanent reduction in force
15 Personal reasons
16 Promoted within the hospital or system
17 Promoted at another hospital or organization
18 Performance or disciplinary issues
19 Relocation
20 Retirement
21 Terminated by hospital
22 Transfers within the hospital
23 Transfer to another hospital or entity in the system
24 Unable to Determine

• The employee should not be prompted by the list of
allowable values above rather allow them to give a
reason in their own words and use the list of allowable
values to categorize the reason.




Inclusion Exclusion
Full-time and part-time RN, APN, Per diems, contractors, consultants,
LPN/LVN and UAP temporary agency, travelers, students
or other non-permanent employees.



Data Element Name: RN Hours [Contract/Agency]

Collected For: NSC-9.1, 9.2, 9.3, 9.4, 10.1, 10.2

Definition: Total number of productive hours worked by Registered
Nurses contracted to the facility with direct patient care
responsibilities.

Suggested Data
Collection Question: What is the total number of productive hours worked by
Registered Nurses with direct patient care responsibilities
contracted to the facility during the calendar month?

Format: Length: 5
Type: Alphanumeric
Occurs: 1 for overall rate
1 per strata


• Outliers should be checked as part of quality assurance

• Staffing System

Inclusion Exclusion
None None



Data Element Name: RN Hours [Employee]

Collected For: NSC-9.1, 9.2, 9.3, 9.4, 10.1, 10.2

Definition: Total number of productive hours worked by Registered
Nurses with direct patient care responsibilities for at least
50% or greater of work time, who are replaced if they call in
sick and are employed directly by the facility.

Suggested Data
Registered Nurses with direct patient care responsibilities for
at least 50% or greater of work time, who are replaced if they
call in sick and are employed directly by the facility during
the calendar month?

Format: Length: 5
Type: Alphanumeric
Occurs: 1 for overall rate
1 per strata



• Staffing System

Inclusion Exclusion
None None



Data Element Name: Separations APN

Collected For: NSC-11.1

Definition: The total number of employment separations for eligible
Advanced Practice Nurses during the calendar month.

Suggested Data
Collection Question: What was the total number of employment separations for
eligible Advance Practice Nurses during the calendar
month?

Format: Length: 4
Type: Numeric
Occurs: 1


Notes for Abstraction: Separations are counted as of the last day worked.
Therefore, an employee separation is credited to the month
of the last day worked, even if the resignation was submitted
in the prior month.


Inclusion Exclusion
Advance practice nurses (APN) engaged Advance practice nurse (APN) per
in direct patient care positions or related diems, contractors, consultants,
supervisory positions and positions for temporary agency, travelers, students
which an advanced (RN) nursing degree or other non-permanent employees.
is a specific condition of hire. Voluntary uncontrolled separations due
to: death, disability, illness, pregnancy,
relocation, military service, education,
retirement, promotion, performance or
discipline, cutbacks due to mergers,
cyclical layoffs, or in other permanent
reductions in force. Transfers should
be excluded when the voluntary
turnover metric is calculated at the
organization level.



Data Element Name: Separations LPN/LVN


Definition: The total number employment separations for eligible
Licensed Practical Nurse and Licensed Vocational Nurse
staff during the calendar month.

Suggested Data
eligible Licensed Practical Nurses and Licensed Vocational
Nurses during the calendar month?

Format: Length: 4
Type: Numeric
Occurs: 1


in the prior month.


Inclusion Exclusion
Licensed Practical Nurses and Voluntary uncontrolled separations due
Licensed Vocational Nurses to: death, disability, illness, pregnancy,
organization level.



Data Element Name: Separations RN


Definition: The total number of employment separations from eligible
Registered Nurse staff during the calendar month.

Suggested Data
eligible Registered Nurses during the calendar month?

Format: Length: 4
Type: Numeric
Occurs: 1


in the prior month.


Inclusion Exclusion
Registered Nurses Voluntary uncontrolled separations due
organization level.



Data Element Name: Separations UAP


Definition: The total number of employment separations for eligible
Unlicensed Assistive Personnel (UAP) staff during the
calendar month.

Suggested Data
eligible nurse assistants for the calendar month?

Format: Length: 4
Type: Numeric
Occurs: 1


in the prior month.


Inclusion Exclusion
Unlicensed Assistive Personnel (UAP) Voluntary uncontrolled separations due
organization level.



Data Element Name: Sex

Collected For: 1, 2, 3, 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2

Definition: The patient's documented sex on arrival at the hospital.

Suggested Data
Collection Question: What was the patient’s sex on arrival?

Format: Length: 1
Type: Character
Occurs: 1

Allowable Values: M = Male
F = Female
U = Unknown

Notes for Abstraction: • Collect the documented patient’s sex at admission or the
first documentation after arrival.
• Consider the sex to be unable to be determined and
select “Unknown” if:
o The patient refuses to provide their sex.
o Documentation is contradictory.
o Documentation indicates the patient is a Transexual.
o Documentation indicates the patient is a
Hermaphrodite.

Sources: • Emergency department record
• Face sheet
• Nursing admission notes
• Progress notes

Inclusion Exclusion
None None



Data Element Name: Specific Event Type


Definition: The specific criteria within the event type.

Suggested Data
Collection Question: What is the specific criterion by which the event is classified?

Format: Length: 1
Type: Alphanumeric
Occurs: 1

Allowable Values: 1 ASB Asymptomatic bacteriuria
2 SUTI Symptomatic urinary tract infection
3 LCBI Laboratory Confirmed Bloodstream Infection
4 CSEP Clinical Sepsis
5 PNU1 Clinically Defined Pneumonia
6 PNU2 Pneumonia with Specific Laboratory Findings
7 PNU3 Pneumonia in Immunocompromised Patients
8 UTD Unable to Determine from documentation

Notes for Abstraction: Please refer to the criteria provided in Appendix F.

• Laboratory records
• Nurses Notes
• Progress notes
• Radiology records

Inclusion Exclusion
See Appendix F, Tables 6.1 – 8.5 None



Data Element Name: Survey Date


Definition: The date the PES-NWI nursing survey was completed by the
nurse.

Suggested Data
Collection Question: What is the date the nursing survey was completed by the
nurse?

Type: Date
Occurs: 1

DD = Day (01-31)


Index (PEWS-NWI)

Inclusion Exclusion
None None



Data Element Name: Survey Distribution Date


Definition: The date the PEW-NWI nursing survey is distributed or
made available to the nursing staff.

Suggested Data
Collection Question: What is the date the nursing surveys were distributed or
made available?

Type: Date
Occurs: 1

DD = Day (01-31)


Index (PEWS-NWI) survey collection tool.

Inclusion Exclusion
None None



Data Element Name: Total Number of Nurses Surveyed


Definition: The total number of PES-NWI eligible nurses in this survey
period.

Suggested Data
Collection Question: What is the total number of eligible nurses in this survey
period?

Format: Length: 5
Type: Numeric
Occurs: 1



• Human resources records
• Payroll records
• Staffing system reports

Inclusion Exclusion
• Registered Nurses with direct patient • New hires of less than 3 months
care responsibilities for 50% or • Agency, traveler or contract nurses
greater of their job • Nurses in management,
• Full time, part time, and PRN or per supervisory, or educator roles with
diem RN’s employed by the hospital direct patient care responsibilities
• Eligible nurses from all hospital units less than 50% of their job, whose
primary responsibility is
administrative in nature



Data Element Name: Total Number of Surveys


Definition: The total number of PES-NWI surveys submitted.

Suggested Data
Collection Question: What is the total number of surveys submitted?

Format: Length: 5
Type: Numeric
Occurs: 1


• Unit-level findings should only be reported for units with 5
or more respondents.

Index (PES-NWI) survey collection tool

Inclusion Exclusion
None None



Data Element Name: Type of Restraint


Definition: A designated restraint design or location of application.

Suggested Data
Collection Question: What type of physical restraint was in place on the day of the
prevalence study?

Format: Length: 1
Type: Alphanumeric
Occurs: 3

Allowable Values:
1 Limb (including soft or leather)
2 Vest
3 Other
4 Unable to Determine from documentation

Notes for Abstraction: Indicate all the restraints that apply.

• Graphic sheets
• Nurses notes
• Patient Observation Worksheet
• Pressure ulcer / restraint prevalence study worksheet or
data collection tool
• Progress notes




Inclusion Exclusion
Any manual method, physical or A restraint does not include devices,
mechanical device, material, or equipment such as orthopedically prescribed
that immobilizes or reduces the ability of a devices, surgical dressings or
patient to move his or her arms, legs, bandages, protective helmets, or other
body or head freely. For example: methods that involve the physical
• Tucking a patient’s sheets in so tightly holding of a patient for the purpose of
that the patient cannot move conduction routine physical
• Use of a “net bed” or an “enclosed examinations or tests, or to protect the
bed” that prevents the patient from patient from falling out of bed, or to
freely exiting the bed. (except permit the patient to participate in
placement of a toddler in an activities without the risk of physical
“enclosed” or “domed” crib) harm. For example:
• Use of “Freedom” splints that • Use of an IV arm board to stabilize
immobilize a patient’s limb an IV line is generally not
• Using side rails to prevent a patient considered a restraint. However, if
from voluntarily getting out of bed the arm board is tied down (or
• Geri chairs or recliners, only if the otherwise attached to the bed), the
patient cannot easily remove the use of the arm board would be
restraint appliance and get out of the considered a restraint.
chair on his or her own • A mechanical support used to
Note: Generally, if a patient can easily achieve proper body position,
remove a device, the device would not be balance, or alignment so as to allow
considered a restraint. In this context greater freedom of mobility that
“easily remove” means that the manual would be possible without the use
method, device, material, or equipment of such a support, i.e. leg braces for
can be removed intentionally by the walking, neck, head or back braces
patient in the same manner as it was to sit upright.
applied by the staff (e.g., side rails are put • Hand mitts when NOT pinned or
down, not climbed over: buckles are otherwise attached to bedding or
intentionally unbuckled; ties or knots are used in conjunction with a wrist
intentionally untied; etc.) considering the restraint.
patient’s physical condition and ability to
accomplish objective (e.g., transfer to a
chair, get to the bathroom in time).
CMS Hospital Conditions of Participations: Interpretive Guidelines available at
http://www.cms.hhs.gov accessed March 2009



Data Element Name: Type of Unit

Collected For: NSC 2, 3, 4, 5, 9.1, 9.2, 9.3, 9.4, 10.1, 10.2, 11.1, 11.2, 11.3

Definition: Unit type reflects the patient population and the service line.
It is used in risk stratification, so that reporting occurs for
similar units.

Suggested Data
Collection Question: What is the type of unit?

Format: Length: 1
Type: Alphanumeric
Occurs: 1

Allowable Values:
1 Critical Care – adult
2 Step-down – adult
3 Medical - adult
4 Surgical - adult
5 Med-Surg Combined - adult
6 Mixed acuity – adult




• Hospital unit plan
• Unit nursing managers

Inclusion Exclusion
None None



Data Element Name: UAP Hours [Contract/Agency]

Collected For: NSC-9.1, 9.2, 9.3, 9.4, 10.2

Definition: Total number of productive hours worked by Unlicensed
Assistive Personnel (UAP) contracted to the facility with
direct patient care responsibilities.

Suggested Data
Unlicensed Assistive Personnel (UAP) with direct patient
care responsibilities contracted to the facility during the
calendar month?

Format: Length: 5
Type: Alphanumeric
Occurs: 1 per strata


• Personnel meeting the definition for Unlicensed Assistive
Personnel (UAP) should be included in this category –
even if they are in a state that has instituted licensure for
these health care workers.

• Staffing System

Inclusion Exclusion
None None



Data Element Name: UAP Hours [Employee]

Collected For: NSC-9.1, 9.2, 9.3, 9.4, 10.2

Definition: Total number of productive hours worked by Unlicensed
Assistive Personnel (UAP) with direct patient care
responsibilities, who are replaced if they call in sick and are
employed directly by the facility.

Suggested Data
Unlicensed Assistive Personnel (UAP) with direct patient
care responsibilities, who are replaced if they call in sick and
are employed directly by the facility during the calendar
month?

Format: Length: 5
Type: Alphanumeric
Occurs: 1


• Personnel meeting the definition for Unlicensed Assistive
Personnel (UAP) should be included in this category –
even if they are in a state that has instituted licensure for
these health care workers.

• Staffing System

Inclusion Exclusion
None None



Data Element Name: Umbilical Catheter Days


Definition: Any day that a neonate has an umbilical catheter in place at
the time the count is done. A neonate with an umbilical
catheter and a central line in place on a given day is counted
as one umbilical catheter day. This daily count is aggregated
/ summed across the days of the month to provide the total
number of umbilical catheter days for the month for each
birth weight category in the NICU location.

Suggested Data
Collection Question: What is the total number of umbilical catheter days in the
NICU for this birth weight category for the month?

Format: Length: 5
Type: Numeric


• This data element is collected only for the NICU population.
• Umbilical catheter days should be collected in a consistent manner (e.g., at the
same time each day).
• A separate Umbilical Catheter Days total is collected for each birth weight
category.

• Nursing notes
• Operative record
• Progress notes

Inclusion Exclusion
None None



Data Element Name: Ventilator Days

Collected For: NSC 8.1, 8.2

Definition: For each day of the month, at the same time each day,
record the number of patients, by eligible reporting strata,
who are on a ventilator. This daily count is aggregated /
summed across the days of the month to provide the total
number of ventilator days for the month for each ICU
Location and for each Birth weight Category in the NICU.

Suggested Data
Collection Question: What is the total number of ventilator days for this ICU
Location or birth weight category for the month?

Format: Length: 5
Type: Numeric


• Ventilator days should be counted in a consistent manner (e.g., at the same time
each day).
• A separate ventilator day count is collected for each birth weight category and
ICU location.

• Respiratory therapy notes
• Graphic sheets
• Nursing notes
• Progress notes

Inclusion Exclusion
None None



Data Element Name: Year

Collected For: NSC 4, 5, 6, 7.1, 7.2, 7.3, 8.1, 8.2, 9.1, 9.2, 9.3, 9.4, 10.1,
10.2, 11.1, 11.2, 11.3

Definition: The 4-digit year during which the measure specific episode
occurred.

Suggested Data
Collection Question: What was the year during which the measure specific
episode occurred?

Format: Length: 4
Type: Alphanumeric
Occurs: 1

Allowable Values: YYYY = Year (2001 – Current Year)


• Organization-specific data collection documentation
(electronic or manual)

Inclusion Exclusion
None None



**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR NURSING-
SENSITIVE CARE PERFORMANCE MEASURES**

Measure Information Form

Measure Set: Nursing-Sensitive Care (NSC)

Set Measure ID: NSC-1

Performance Measure Name: Death among surgical inpatients with treatable serious
complications

Description: Surgical inpatients with complications of care whose discharge status is
death.

Note: This MIF is included as part of the NSC measure set, provided in a consistent
format to assist in the implementation of the NSC set. Please refer to the Agency for
Healthcare Research and Quality (AHRQ) website for complete measure specifications.
Patient Safety Indicator (PSI) Technical Specifications:
http://www.qualityindicators.ahrq.gov/psi_download.htm

Rationale: Nursing care is an integral part of patient care processes in the acute care
hospital environment. Research in the past decade has been undertaken to develop an
evidence base for the relationship between patient outcomes potentially sensitive to
nursing (OPSN) and nurse staffing in the acute inpatient setting. For example, in the
study Nurse Staffing and Patient Outcomes in Hospitals, Needleman et al. used a large
sample of hospital administrative data from 1997 to examine the relationship between
selected patient outcomes potentially sensitive to nursing and nurse staffing, for medical
and surgical patients. Analysis of the data indicated that the outcome of death among
major surgery patients who developed specified complications (failure to rescue) was
associated statistically with nurse staffing variables. Key nursing functions of patient
assessment and surveillance are important in the identification of patient complications,
the implementation of early interventions and the potential avoidance of adverse patient
outcomes. Measurement of this patient-centered outcome, together with nurse staffing-
related variables and other metrics of nursing care, may identify opportunities to
enhance patient care and positively influence patient outcomes.

Type of Measure: Outcome

Improvement Noted as: A decrease in the rate.

Numerator Statement: All discharges with a disposition of “deceased” among cases
meeting the inclusion and exclusion rules for the denominator.

Included Populations: Not applicable

NSC Measure Set NSC-1-1


Excluded Populations: None

Data Elements:
Discharge Status

Denominator Statement: All surgical discharges age 18 years and older defined by
specific DRGs and an ICD-9-CM code for an operating room procedure, principal
procedure within 2 days of admission OR admission type elective with potential
complications of care listed in Death among Surgical definition (e.g., pneumonia,
DVT/PE, sepsis, shock/cardiac arrest, or GI hemorrhage/acute ulcer).

For complete tables and technical specifications, see the AHRQ Patient Safety Indicator
(PSI) Technical Specifications

Included Populations: Discharges with:
• A listed ICD-9-CM Diagnosis-Related Group (DRG) for Operating Room
Procedure, Surgical Discharge DRG or Surgical Discharge MS-DRG
• ICD-9-CM Principal Procedure Date within 2 days of admission OR
Admission Type of elective
• Potential complications of care (e.g., pneumonia, DVT/PE, sepsis,
shock/cardiac arrest, or GI hemorrhage/acute ulcer).

Excluded Populations:
• Patients greater than or equal to 90 years of age
• Patients less than 18 years of age
• Patients discharged with an MDC of 15 (newborns and other neonates)
• Patients transferred to an acute care facility

Note: Additional exclusion criteria is specific to each diagnosis

Populations by Complication:

DVT/PE:

Included: Discharges with:
• An ICD-9-CM Other Diagnosis Codes of Pulmonary Embolism/Deep Vein
Thrombosis

Excluded: Discharges with:
• Preexisting (principal diagnosis or secondary diagnosis present on
admission, if known) of pulmonary embolism or deep vein thrombosis
• Abortion-related and postpartum obstetric pulmonary embolism

Pneumonia:




• An ICD-9-CM Other Diagnosis Codes of Pneumonia

• Preexisting condition (principal diagnosis or secondary diagnosis present
on admission, if known) of pneumonia or 997.3
• Any diagnosis code for viral pneumonia
• MDC 4 Diseases/disorders of Respiratory System
• Any ICD-9-CM Other Diagnosis Codes of Immunocompromised States

Sepsis:

• An ICD-9-CM Other Diagnosis Codes of Sepsis or Septicemia

o An ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis
Codes of immunocompromised state
and
o ICD-9-CM Principal Diagnosis Code of infection or sepsis
and
o A length of stay 3 days or less

Shock or Cardiac Arrest:

• An ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis
Codes of shock or cardiac arrest
• An ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure
Code for resuscitation or cardiac massage

Codes of hemorrhage, trauma or GI hemorrhage
• An MDC 4 diseases/disorders of respiratory system
• An MDC 5 diseases/disorders of circulatory system
• A preexisting condition (principal diagnosis or secondary diagnosis
present on admission, if known) of shock or cardiac arrest
Codes of abortion-related shock

GI Hemorrhage/Acute Ulcer:

Codes of GI hemorrhage/acute ulcer, gastric, duodenal ulcer, peptic ulcer,
gastrojejunal ulcer, gastritis and duodenitis ulcer



Codes of trauma
• An MDC 6 diseases/disorders of digestive system
• An MDC 7 diseases/disorders of hepatobiliary system and pancreas
• A preexisting condition (principal diagnosis or secondary diagnosis
present on admission, if known) of GI hemorrhage/acute, alcoholism,
Codes of 280.0 or 285.1

Risk Adjustment: Yes
Risk Adjustment is accomplished through the use of the AHRQ co-morbidity software
and covariates integrated into the AHRQ PSI module. AHRQ provides ongoing support
through its Quality Indicators Software, specifically the Patient Safety Indicator module.
For more information about the technical specifications, see the AHRQ Patient Safety
Indicator (PSI) Technical Specifications.

Data Collection Approach: Retrospective, data sources for required data elements
include administrative data and medical records.

Data Accuracy:
• Variation may exist in the assignment of ICD-9-CM codes; therefore, coding
practices may require evaluation to ensure consistency.
• The principal procedure should have occurred on the day of admission or the day
following admission.
• For questions regarding the technical specifications for the Agency for
Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs) and
Inpatient Quality Indicators (IQIs), contact: support@qualityindicators.ahrq.gov
Or: (888) 512–6090.
• For questions regarding CMS’ calculations of the PSIs and IQIs for the
RHQDAPU program, contact: AHRQmeasuresforRHQDAPU@mathematica-
mpr.com.

Measure Analysis Suggestions: Organizations may wish to further examine the
occurrences within the individual complication categories (e.g., sepsis, pneumonia, GI
bleeding, shock/cardiac arrest or DVT/PE).

Sampling: No

Data Reported as: Aggregate rate generated from count data as a proportion

Selected References:
• Agency for Healthcare Research and Quality. Patient Safety Indicator (PSI)
Technical Specifications Version 4.0 (June 2009):



• Aiken L, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and
patient mortality, nurse burnout, and job satisfaction. JAMA. 2002:288:1987-1993.
• Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. Nurse Staffing and
Patient Outcomes in Hospitals. Health Resources and Services Administration
(HRSA) Report No. 230-99-0021; February 28, 2001.
• Needleman J, Buerhaus PI, Mattke S, Stewart M. Nurse-staffing levels and the
quality of care in hospitals. N Engl J Med. 2002;346(22):1717-1722.
• Liber JH, Williams SV, Krakauer H. Schwartz JS. Hospital and patent characteristics
associated with death after surgery. A study of adverse occurrence and failure to
rescue. Med Care. 1992;30(7):615-629.

Performance Measure Source / Developer:
Needleman, Jack, et al.
Agency for Healthcare Research and Quality (AHRQ)





Measure Set: Nursing-Sensitive Care

Performance Measure ID: NSC-2
Set Measure Performance Measure Name
ID#
NSC-2a Patients that have at least one category/stage II or greater hospital-
acquired pressure ulcer on the day of the prevalence study – All Units
– overall rate (NSC-2b, c, d, e, f and g)
NSC-2b Patients that have at least one category/stage II or greater hospital-
acquired pressure ulcer on the day of the prevalence study by Type of
Unit – Critical Care - adult
NSC-2c Patients that have at least one category/stage II or greater hospital-
Unit – Step-down - adult
NSC-2d Patients that have at least one category/stage II or greater hospital-
Unit – Medical - adult
NSC-2e Patients that have at least one category/stage II or greater hospital-
Unit – Surgical - adult
NSC-2f Patients that have at least one category/stage II or greater hospital-
Unit – Med-Surg Combined - adult
NSC-2g Patients that have at least one category/stage II or greater hospital-
Unit – Mixed Acuity - adult

Performance Measure Name: Pressure Ulcer Prevalence (Hospital-Acquired)

Description: The total number of patients that have hospital-acquired (nosocomial)
category/stage II or greater pressure ulcers on the day of the prevalence study.

Rationale: The incidence of hospitalized patients developing pressure ulcers has been
reported to range from 2.7 percent (Gerson, 1975) to 29.5 percent (Clarke and Kadhom,
1988). Certain circumstances (e.g., immobility, incontinence, impaired nutritional status,
critical illness, etc.) further increase the risk for selected patients. The development of
hospital acquired pressure ulcers (HAPU) places the patient at risk for other adverse
events and may lead to increased lengths of stay. HAPUs also increase resource
consumption and costs. Recommendations from the guideline Pressure Ulcers in
Adults: Prediction and Prevention (AHCPR, 1992) include the identification of



individuals at risk and early intervention with a goal of maintaining and improving tissue
tolerance in order to prevent injury. In most vulnerable patients, reducing risk factors
and implementing preventive/treatment measures will reduce the incidence of new
pressure ulcer development and prevent the worsening of existing ulcers. Nurses and
nursing-care interventions play an important role in pressure ulcer prevention and
management. The use of this prevalence measure allows organizations to monitor this
important patient outcome at points in time and examine institutional processes.


Improvement Noted as: Decrease in rate

Numerator Statement: Patients that have at least one category/stage II or greater
hospital-acquired pressure ulcer on the day of the prevalence study.

Included Populations:
• Hospital-acquired pressure ulcers (ulcers discovered or documented after
the first 24 hours from the time of inpatient admission)
• Category/stage II or greater pressure ulcers
• Unstageable/unclassified pressure ulcers
• Suspected deep tissue injury

• None

Data Elements:
• Observed Pressure Ulcer
• Observed Pressure Ulcer – Hospital-Acquired
• Observed Pressure Ulcer – Category/stage

Denominator Statement:
All patients surveyed for the study.

Included Populations: Patients 18 years or older who are admitted to all eligible
units that are surveyed for the study.

• Patients who refuse to be assessed
• Patients who are off the unit at the time of the prevalence study, i.e.
• Patients who are medically unstable at the time of the study for whom
assessment would be contraindicated at the time of the study, i.e.
unstable blood pressure, uncontrolled pain, or fracture waiting repair.
• Patients who are actively dying and pressure ulcer prevention is no longer
a treatment goal.



Data Elements:
• Admission Date
• Birthdate
• Sex
• Type of Unit
• Prevalence Study Date

Risk Adjustment: by stratification

Data Collection Approach: Concurrent for required data elements

Data Accuracy:
• Review and follow the Prevalence Study Methodology (see Appendix E).
• Review and follow International NPUAP-EPUAP Pressure Ulcer Guidelines (see
Appendix D).
• For the purposes of this measure, and to maximize reliability across
organizations, hospital-acquired ulcers (discovered or documented after the first
24 hours from the time of inpatient admission) category/stage II or greater ulcers
are included in the numerator.
• The patient observation/exam and the medical record review must be conducted
on the same day.
• An ulcer of category/stage II or greater observed after the first 24 hours from the
time of inpatient admission AND for which there is no documentation in the
record indicating the date of first discovery; should be considered as hospital-
acquired.
• Skin breakdown due to arterial occlusion, venous insufficiency, diabetes related
neuropathy, or incontinence dermatitis are not pressure ulcers.
• The terms “actively dying” and “medically unstable” are terms used to
characterize patients who cannot safely be turned for physiological reasons.
Active dying is considered the last few days of life when blood flow to organs
(e.g., brain, heart, kidneys) is decreasing, respiratory distress is increasing, and
physiological instability is apparent, making turning unrealistic. “Medically
unstable” people may have poor hemodynamic profiles or distress so severe that
they cannot safely be turned for examination of the back, sacrum scapula,
ischea, back of head, etc. The nature of the instability will vary e.g., some will
require upright position to breathe, others cannot tolerate movement because of
changes in hemodynamics (reduction) or intracranial pressure (increase).
• Eligible reporting units for this measure are defined by the allowable values for
the data element, Type of Unit.

Measure Analysis Suggestions:
Facilities may also choose to collect data on additional unit types such as pediatric,
psychiatric or rehabilitation.

Sampling: No



Data Reported as: Aggregate rate generated from count data reported as a proportion

• AHRQ, Agency for Healthcare Quality and Research (2006). Numbers of patients
with pressure sores increasing. http://hcup.ahrq.gov/HCUPnet.asp
• Allman, R. (1997). Pressure ulcer prelavence, incidence and risk factors and
impact. Clinics in Geriatric Medicine, 13(3), 421-436.
• Allman, R. (2001). Pressure ulcers: Using what we know to improve quality of care.
Journal of the American Geriatric Society, 49, 996-997.
• Allman, R., Goode, P., Burst, N., Bartolucci, A., & Thomas, D. (1999) Pressure
ulcer, hospital complications, and disease severity: Impact on hospital costs and
length of stay. Advances in Wound Care, 12(1), 22-30.
• Anderson, C. & Rappl, L. (2004). Lateral rotation mattresses for wound healing.
Ostomy/Wound Management, 50(4), 50-62.
• Baumgarten M, Margolis DJ, Localio AR, Kagan SH, Lowe RA, Kinosian B, Holmes
JH, Abbuhl SB, Kavesh W, Ruffin A. Pressure ulcers among elderly patients early in
the hospital stay. J Gerontol A Biol Sci Med Sci. 2006 Jul;61(7):749-54.
• Black J, Baharestani M, Cuddigan J, Dorner B, Edsberg L, Langemo D, Posthauer
ME, Ratliff C, Taler G; National Pressure Ulcer Advisory Panel.National Pressure
Ulcer Advisory Panel's updated pressure ulcer staging/categorizing system.
Dermatol Nurs. 2007 Aug;19(4):343-9; quiz 350.
• Braden BJ, Maklebust J. Preventing pressure ulcers with the Braden scale: An
update on this easy-to-use tool that assesses a patient’s risk. Am J Nurs.
2005;105:70-72.
• Dale, M.C., Burns, A., Panter, L., & Morris, J. (2001). Factors affecting survival of
elderly nursing home residents. Internal Journal of Geriatric Psychiatry. 16, 70-76.
• European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory
Panel. Prevention and treatment of pressure ulcers: quick reference guide.
Washington DC: National Pressure Ulcer Advisory Panel; 2009.
• Fogerty MD, Abumrad NN, Nanney L, Arbogast PG, Poulose B, Barbul A. Risk
factors for pressure ulcers in acute care hospitals. Wound Repair Regen. 2008 Jan-
Feb;16(1):11-8.
• Hart S, Bergquist S, Gajewski B, Dunton N. Reliability testing of the National
Database of Nursing Quality Indicators pressure ulcer indicator. J Nurs Care Qual.
2006 Jul-Sep;21(3):256-65.
• Hopkins, A., Dealey, C., Bale, S., Defloor, T., & Worboys, F. (2006). Patient stories
of living with a pressure ulcer. Journal of Advanced Nursing, 56(4), 345-353.
• Horn SD, Bender SA, Ferguson ML, Smout RJ, Bergstrom N, Taler G, Cook AS,
Sharkey SS, Voss AC. The National Pressure Ulcer Long-Term Care Study:
pressure ulcer development in long-term care residents. J Am Geriatr Soc. 2004
Mar;52(3):359-67.
• IOM (Institute of Medicine) (1999). To error is human: Building a safer health
system. Washington D.C: National Academy of Sciences.
• Kottner J, Tannen A, Halfens R, Dassen T.Does the number of raters influence the
pressure ulcer prevalence rate? Appl Nurs Res. 2009 Feb;22(1):68-72.


• Langemo, K.K., Melland, H., Hanson, K., Olson, B., & Hunter, S. (2000). The lived
experience of having a pressure ulcer: A qualitative analysis. Advances in Skin and
Wound Care, 13(5), 225-235.
• Maklebust, J. (2005). Pressure ulcers: The great insult. Nursing Clinics of North
America, 40, 365-389.
• Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C.
Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv
Nurs. 2006 Apr;54(1):94-110.
• Pressure Ulcers in Adults: Prediction and Prevention (AHCPR, 1992). URL:
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409
• Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline
Number 3. AHCPR Pub. No. 92-0047:May 1992
• Rastinehad, D. (2006). Pressure ulcer pain. Journal of Wound, Ostomy &
Continence Nursing, 33, 252-257.
• Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA.Treatment of
pressure ulcers: a systematic review. JAMA. 2008 Dec 10;300(22):2647-62.
• Redelings, M.D., Lee, N.E., Sorvillo, F. (2005). Pressure ulcers: More lethal than we
thought? Advances in Skin and Wound Care, 18, 367-372.
• Stechmiller JK, Cowan L, Whitney JD, Phillips L, Aslam R, Barbul A, Gottrup
F,Gould L, Robson MC, Rodeheaver G, Thomas D, Stotts N. Guidelines for the
prevention of pressure ulcers. Wound Repair Regen. 2008 Mar-Apr;16(2):151-68.
• Whitney J, Phillips L, Aslam R, Barbul A, Gottrup F, Gould L, Robson
MC,Rodeheaver G, Thomas D, Stotts N. Guidelines for the treatment of pressure
ulcers. Wound Repair Regen. 2006 Nov-Dec;14(6):663-79.
• Whittington KT, Briones R. National Prevalence and Incidence Study: 6-year
sequential acute care data. Adv Skin Wound Care. 2004 Nov-Dec;17(9):490-4
• Wound, Ostomy and Continence Nurses Society. (2003) Guideline for Prevention
and Management of Pressure Ulcers. WOCN: Glenview, IL
• Zulkowski, K., Langemo, D., Posthauer, M.E., & the National Pressure Ulcer
Advisory Panel. (2005). Coming to consensus on deep tissue injury. Advances in
Skin & Wound Care, 18(1), 28-29.

Collaborative Alliance for Nursing Outcomes (CALNOC)






Set Measure Performance Measure by Type of Unit
ID#
NSC-3a Patients that have vest and/or limb restraint (upper or lower body or
both) on the day of the prevalence study – All Units – overall rate
(NSC-3b, c, d, e, f and g)
NSC-3b Patients that have vest and/or limb restraint (upper or lower body or
both) on the day of the prevalence study by Type of Unit – Critical
Care - adult
NSC-3c Patients that have vest and/or limb restraint (upper or lower body or
both) on the day of the prevalence study by Type of Unit – Step-down
- adult
NSC-3d Patients that have vest and/or limb restraint (upper or lower body or
both) on the day of the prevalence study by Type of Unit – Medical -
adult
NSC-3e Patients that have vest and/or limb restraint (upper or lower body or
both) on the day of the prevalence study by Type of Unit – Surgical -
adult
NSC-3f Patients that have vest and/or limb restraint (upper or lower body or
both) on the day of the prevalence study by Type of Unit – Med-Surg
Combined - adult
NSC-3g Patients that have vest and/or limb restraint (upper or lower body or
both) on the day of the prevalence study by Type of Unit – Mixed
Acuity - adult

Performance Measure Name: Restraint Prevalence (vest and limb)

Description: Total number of patients that have vest and/or limb restraint (upper or
lower body or both) on the day of the prevalence study.

Rationale:
The utilization of physical restraints in the acute care setting has increasingly been the
subject of interest by healthcare researchers, practitioners, regulatory, and accrediting
bodies. Restraint use has the potential to produce serious consequences including
physical and psychological harm. Potential physical complications can include the
development of pressure ulcers, nerve and joint injuries, and even death from
strangulation. Clinical practice guidelines suggest that the incidence and/or prevalence
of restraint use should be monitored and that a range of effective prevention strategies
and alternative therapies be implemented. The use of physical restraints to prevent falls



has been refuted because restraints limit mobility, contribute to injuries, and don’t
prevent falls. Agostini and colleagues examined literature related to fall prevention via
restraint and side rail use, as well as fall rates when restraints were removed. Six
studies found that restraints were associated with increased injuries, and restraint and
side rail removal did not increase fall rates. Evans, Wood, and Lambert also examined
the literature and found 16 studies that examined restraint minimization, concluding that
restraint-minimization programs involving effective staff education can reduce injuries
and do not increase fall rates. By measuring the use of physical restraints at points in
time (prevalence), a hospital can monitor its performance with a goal of reducing
restraint use to the degree consistent with the patient population served, clinical
services offered and medical necessity.

Type of Measure: Process

Improvement Noted as: A decrease in rate.

Numerator Statement: Patients that have a vest restraint and/or limb restraint (upper
or lower or both) on the day of the prevalence study.

Included Populations: Not applicable.

• Restraints that are only associated with medical, dental, diagnostic, or
surgical procedures and is based on standard practice for the procedure
(sometimes referred to as “treatment restraints”)
• seclusion
• restraint uses that are forensic or correctional restrictions used for security
purposes unrelated to clinical care
• devices used to meet the assessed needs of a patient who requires adaptive
support or a medical protective device

Data Elements:
• Physical Restraint
• Type of Restraint

Denominator Statement: All patients who are surveyed for the study.

Included Populations: Patients 18 years or older who are admitted to all eligible
units that are surveyed for the study.

• Patients who are off the unit at the time of the prevalence study, i.e.

Data Elements:



• Admission Date
• Birthdate
• Prevalence Study Date
• Sex
• Type of Unit

Risk Adjustment: No

Data Collection Approach: Concurrent

Data Accuracy:
• Review and follow the Prevalence Study Methodology (see Appendix E)
• Each patient on the assigned unit should be observed (i.e., observations are not
to be referred by staff for those patients thought to be restrained)
• Observation Units (must operate 24 hours each day and not close overnight) are
included under appropriate unit type (e.g., medical or surgical)

Facilities may also choose to collect data on additional unit types such as pediatric or
rehabilitation.

Sampling: No

Data Reported as: Aggregate rate generated from count data reported as a proportion

• CMS Conditions of Participation, §482.13(e). Available at: http://www.cms.hhs.gov
• Davies B, Danseco E, Ploeg J, Heslin, K, Stansfield M, Santos J & Edwards, N.
(2006). Nursing Best Practice Guideline Evaluation User Guide: Restraint
Prevalence Tools. Nursing Best Practice Research Unit, University of Ottawa,
Canada. pp. 1-20.
• Leanne Currie, Ph.D., R.N., Fall and Injury Prevention, In Hughes RG (ed.). Patient
safety and quality: An evidence-based handbook for nurses. (Prepared with support
from the Robert Wood Johnson Foundation.) AHRQ Publication No. 08-
0043.Rockville, MD: Agency for Healthcare Research and Quality; April 2008.
• O’Connell AM, Mion, LC. Use of physical restraints in the acute care setting. In:
Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols
for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003.
p. 251-64.
• Talerico, K.A., Capezuit, E.C. Myths and facts about side rails. Am J Nurs, 2001:
Vol.101:43-48.







Set Measure Performance Measure Name
ID#
NSC-4b Patient falls per 1,000 patient days by Type of Unit – Critical Care -
adult
NSC-4c Patient falls per 1,000 patient days by Type of Unit – Step-down -
adult
NSC-4d Patient falls per 1,000 patient days by Type of Unit – Medical - adult
NSC-4e Patient falls per 1,000 patient days by Type of Unit – Surgical - adult
NSC-4f Patient falls per 1,000 patient days by Type of Unit – Med-Surg
Combined - adult
NSC-4g Patient falls per 1,000 patient days by Type of Unit – Mixed Acuity -
adult

Performance Measure Name: Patient Falls

Description: All documented falls with or without injury, experienced by patients in a
calendar month.

Rationale: Patient falls occurring during hospitalization can result in serious and even
potentially life threatening consequences for many patients. Efforts to reduce this
adverse event have included the development of tools to assess and identify patients at
risk of falling and the implementation of fall prevention protocols. More recently,
research has suggested that staffing on patient care units, specifically the number of
professional nurses, may impact the incidence of this patient outcome. Nurses are
responsible for identifying patients who are at risk for falls and for developing a plan of
care to minimize that risk. High performance measure rates may suggest the need to
examine clinical and organizational processes related to the identification of, and care
for, patients at risk of falling, and possibly staffing effectiveness on the unit.



Numerator Statement: Total number of patient falls (with or without injury to the
patient) during the calendar month.




• Patient falls occurring while on an eligible reporting unit
• Assisted falls
• Repeat falls

Falls by:
• Visitors
• Students
• Staff members
• Patients from eligible reporting units, however patient was not on unit at
time of fall (e.g., patients falls in radiology department)
• Falls on other unit types (e.g., pediatric, obstetrical, rehab, etc)

Data Elements:
• Admission Date
• Birthdate
• Date of Event
• Event Type
• Number of Patient Falls
• Sex
• Type of Unit

Denominator Statement: Patient days by Type of Unit during the calendar month.

• Inpatients, short stay patients, observation patients and same day surgery
patients who receive care on eligible in-patient units for all or part of a day.
• Adult critical care, step-down, medical, surgical, medical-surgical
combined, and mixed acuity units.
• Any age patient on an eligible reporting unit is included in the patient day
count.

Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, etc)

Data Elements:
• Month
• Patient Days
• Type of Unit
• Year

Risk Adjustment: No

Data Collection Approach: Retrospective – data sources for required data elements
include medical records, hospital risk management reports, incident reports, variance



reports, event reports, etc. Some hospitals may prefer to collect data concurrently at the
time of report completion or filing.

Data Accuracy:
• Eligible reporting units for this measure are defined by the allowable
values for the data element, Type of Unit. Data collection at the specific
unit level captures data on patient outcomes and nurse staffing within a
given unit. Therefore, for the purposes of this measure, patient falls that
occur while off the unit are not counted in the unit-level reporting.
• An eligible reporting unit will report fall data by calendar month. In
addition, each unit that reports fall data, must also collect patient day data
for the same month (as outlined in the data element, Patient Days – also
see Appendix D: Table Patient Day Reporting Methods) in order to
calculate fall rates.
• Fall rate is calculated by multiplying the numerator by 1,000 and then
dividing by the denominator.

Measure Analysis Suggestions: In order to further examine the issue of falls within
your facility it may be useful to calculate the number of patients who were assessed,
who were at risk and what their risk level was. It may also be useful to identify patient
falls that involved staff intervention. To facilitate these analyses, additional data
elements could be collected that are not required for calculating the primary measure
rate.
Facilities may also choose to collect falls data on additional unit types such as pediatric,
psychiatric or rehabilitation. With respect to pediatric unit type an additional exclusion is
recommended.
Exclude: Developmental falls in pediatric patients, falls common in
infants/toddlers as they learn to walk, turn, or run.

Sampling: No

Data Reported As: Aggregate rate generated from count data reported as a ratio.

• American Nurses Association. National Database of Nursing Quality Indicators.
(NDNQI) ANA. Nurse Staffing and Patient Outcomes in the Inpatient Setting.
Washington, DC. American Nurses Publishing. 1996.
• Dall, T., Yaozhu, J., Seifert, R., Maddox, P., & Hogan, P. (2009). The Economic
Value of Professional Nursing. Medical Care 47(1): 97-104.
• Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on
acute care hospital units. Nursing Outlook. 2004; 53:53-59.
• Dunton, N. (April 2008). Take a cue from the NDNQI: Demonstrating the quality of
care on nursing units. Nursing Management.



• Dunton, N., Gajewski, B., Klaus, S., Pierson, B. (2007). The relationship of nursing
workforce characteristics to patient outcomes. OJIN: Online Journal of Issues in
Nursing, 12(3), Manuscript 4.
• Hendrich, A.L., Bender, P.S. & Myhuis, A. Validation of the Hendrich II fall risk
model: a large concurrent case/control study of hospitalized patients. Applied
Nursing Research. 2005 (16(1)): 9-12.
• McCollam, M.E. Evaluation and Implementation of a research-based falls
assessment innovation. Nursing Clinics of North America. 1995; 30(3):507-514.
• Morse, J.M., Morse, et al. Development of a scale to identify the fall-prone patient.
Canadian Journal of Aging. 1989; (8):366-377.
• Savitz, Lucy A., Jones, Cheryl B., Bernard, Shulamit. Advances in Patient Safety:
From Research to Implementation Advances in Patient Safety: From Research to
Implementation Volume 4. Programs, Tools, and Products Quality Indicators
Sensitive to Nurse Staffing in Acute Care Settings. 2005.
• Schmid, N. A. 1989 Federal Nursing Service Award Winner. Reducing patient falls: a
research-based comprehensive fall prevention program. Military Medicine. 1990;
155(5):202-207.
• Unruh L. Licensed nurse staffing and adverse events in hospitals. Medical Care.
2003; 41(1):142-152.
• Yang KP. Relationships between nurse staffing and patient outcomes. Journal of
Nursing Research. 2003; 11(3):149-158.

American Nurses Association (ANA) – National Database for Nursing Quality Indicators
(NDNQI)






Set Measure Performance Measure by Type of Unit
ID#
NSC-5b Patient falls with injury per 1,000 patient days by Type of Unit –
Critical Care - adult
NSC-5c Patient falls with injury per 1,000 patient days by Type of Unit – Step-
down - adult
NSC-5d Patient falls with injury per 1,000 patient days by Type of Unit –
Medical - adult
NSC-5e Patient falls with injury per 1,000 patient days by Type of Unit –
Surgical - adult
NSC-5f Patient falls with injury per 1,000 patient days by Type of Unit – Med-
Surg Combined - adult
NSC-5g Patient falls with injury per 1,000 patient days by Type of Unit – Mixed
Acuity - adult

Performance Measure Name: Falls with Injury

Description: All documented patient falls with an injury level of minor (2) or greater.

Rationale: Patient falls occurring during hospitalization can result in serious and even
potentially life threatening consequences for many patients. Nurses are responsible for
identifying patients who are at risk for falls and for developing a plan of care to minimize
that risk. Short staffing, nurse inexperience and inadequate nurse knowledge could
place patients at risk for injury. High performance measure rates may suggest the need
to examine clinical and organizational processes related to the identification of, and care
for, patients at risk of falling, and possibly staffing effectiveness on the unit.



Numerator Statement: Number of patient falls with an injury level of minor or greater
during the calendar month.

• Patient falls occurring while on an eligible reporting unit
• Falls with Fall Injury Level of 2 “minor” or greater



Falls by:
• Visitors
• Students
• Staff members
• Falls by patients from eligible reporting unit, however patient was not on
unit at time of fall (e.g., patients falls in radiology department)
• Falls on other unit types (e.g., pediatric, obstetrical, rehab, etc)
• Falls with Fall Injury Level of 1 “none”

Data Elements:
• Admission Date
• Birthdate
• Date of Event
• Event Type
• Fall Injury Level
• Sex
• Type of Unit

Denominator Statement: Patient days by Type of Unit during the calendar month.

• Inpatients, short stay patients, observation patients and same day surgery
patients who receive care on eligible in-patient units for all or part of a day.
• Adult critical care, step-down, medical, surgical, medical-surgical
combined, and mixed acuity units.

Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, etc.)

Data Elements:
• Month
• Patient Days
• Type of Unit
• Year

Risk Adjustment: No

Data Collection Approach: Retrospective – data source for required data elements
include medical records, hospital risk management reports, incident reports, variance
reports, event reports, etc. Some hospitals may prefer to collect data concurrently at the
time of report completion or filing.

Data Accuracy:



• “Injury Level” When the initial fall report is written by the staff, the extent of
injury may not yet be known. A method to follow up on the patient’s
condition after 24 hours from the fall must be established.
• A fall injury level of death may be selected only if the fall caused the death
of the patient, not if dying caused the fall.
• Eligible reporting units for this measure are defined by the allowable
values for the data element, Type of Unit.
• An eligible reporting unit will report fall data by calendar month. In
addition, each unit that reports fall data must also collect patient day data
for the same month (as outlined in the data element, Patient Days – also
see Appendix D: Table Patient Day Reporting Methods) in order to
calculate fall with injury rates.
• Fall rate is calculated by multiplying the numerator by 1,000 and then
dividing by the denominator.

Measure Analysis Suggestions: The data element Fall Injury Level captures injury
level outcomes used for the aggregate number of injury falls which is required for rate
calculation and provides the opportunity to further analyze fall injuries by severity.

Facilities may also choose to collect falls data on additional unit types such as pediatric,
psychiatric or rehabilitation. With respect to pediatric unit type an additional exclusion is
recommended.
Exclude: Developmental falls in pediatric patients, falls common in
infants/toddlers as they learn to walk, turn, or run.

Sampling: No

Data Reported As: Aggregate rate generated from count data reported as a ratio.

• Dall, T., Yaozhu, J., Seifert, R., Maddox, P., & Hogan, P. (2009). The Economic
Value of Professional Nursing. Medical Care 47(1): 97-104.
• Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on
acute care hospital units. Nursing Outlook. 2004; 53:53-59.
• Dunton, N. (April 2008). Take a cue from the NDNQI: Demonstrating the quality of
care on nursing units. Nursing Management.
• Dunton, N., Gajewski, B., Klaus, S., Pierson, B. (2007). The relationship of nursing
workforce characteristics to patient outcomes. OJIN: Online Journal of Issues in
Nursing, 12(3), Manuscript 4.
• Hendrich, A.L., Bender, P.S. & Myhuis, A. Validation of the Hendrich II fall risk
model: a large concurrent case/control study of hospitalized patients. Applied
Nursing Research. 2005 (16(1)): 9-12.



• McCollam, M.E. Evaluation and Implementation of a research-based falls
assessment innovation. Nursing Clinics of North America. 1995; 30(3):507-514.
• Morse, J.M., Morse, et al. Development of a scale to identify the fall-prone patient.
Canadian Journal of Aging. 1989; (8):366-377.
• Savitz, Lucy A., Jones, Cheryl B., Bernard, Shulamit. Advances in Patient Safety:
From Research to Implementation Advances in Patient Safety: From Research to
Implementation Volume 4. Programs, Tools, and Products Quality Indicators
Sensitive to Nurse Staffing in Acute Care Settings. 2005.
• Schmid, N. A. 1989 Federal Nursing Service Award Winner. Reducing patient falls: a
research-based comprehensive fall prevention program. Military Medicine. 1990;
155(5):202-207.
• Unruh L. Licensed nurse staffing and adverse events in hospitals. Medical Care.
2003; 41(1):142-152.
• Yang KP. Relationships between nurse staffing and patient outcomes. Journal of
Nursing Research. 2003; 11(3):149-158.

(NDNQI)






Performance Measure ID: NSC- 6
Set Measure Performance Measure by ICU Location
ID#
NSC-6a Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI – All ICU Locations (NSC-6b through NSC-6t)
NSC-6b Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Burn [Burn Critical Care B-Adult]
NSC-6c Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Coronary [Medical Cardiac Critical Care MC-
Adult]
NSC –6d Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Cardiothoracic [Surgical Cardiothoracic Critical
Care Adult SCT-Adult]
NSC-6e Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Medical [Medical Critical Adult M-Adult]
NSC-6f Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Medical/Surgical Major Teaching Hospital
[Combined MS – Adult Major Teaching Hospital MS1]
NSC-6g Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Medical/Surgical Other Hospital [Combined MS
-Adult Other MS0]
NSC-6h Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Neurologic [Neurologic Critical Care N-Adult]
NSC-6i Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Neurosurgical [Neurosurgical Critical Care Adult
NS-Adult]
NSC –6j Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Respiratory [Respiratory Critical Care R-Adult]
NSC-6k Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Surgical [Surgical Critical Care Adult S-Adult]
NSC-6l Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Trauma [Trauma Critical Care Adult T-Adult]
NSC-6m Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Burn [Burn Critical Care Pediatric, B-Ped]
NSC-6n Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Cardiothoracic [Cardiothoracic Critical Care
Pediatric CT-Ped]
NSC-6o Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Medical [Medical Critical Care Pediatric, M-Ped]



NSC-6p Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Medical-Surgical [Medical – Surgical Critical
Care Pediatric, MS-Ped]
NSC-6q Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Neurosurgical [Neurosurgical Critical Care
Pediatric, NS-Ped]
NSC-6r Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Respiratory [Respiratory Critical Care Pediatric,
R-Ped]
NSC-6s Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Surgical [Surgical Critical Care Pediatric, S-Ped]
NSC-6t Intensive Care Unit (ICU) Catheter-Associated Urinary Tract Infection
CAUTI by Location – Trauma [Trauma Critical Care Pediatric, T-Ped]

Performance Measure Name: Catheter-Associated Urinary Tract Infection (CAUTI)
Rate for ICU patients

Description: The rate of CAUTIs in ICU patients.

Rationale: Patients in the ICU are at high risk for infections. The urinary tract is the
most common site of healthcare associated (nosocomial) infection and virtually all
urinary tract infections are caused by instrumentation of the urinary tract. For patients
with indwelling urethral catheters, rates of infection increase as the duration of
catheterization increases. Catheter-associated urinary tract infections (CAUTI) can lead
to other complications such as cystitis, pyelonephritis, and gram-negative bacteremia,
prostatitis, epididymitis, and orchitis in males. Complications associated with CAUTI
cause discomfort to the patient, prolonged hospital stay, and increased cost and
mortality. High rates may suggest the need to examine the clinical and organizational
processes related to the care of patients with indwelling urinary catheters including
adherence to recommended guidelines.


Improvement Noted as: A decrease in the rate

Numerator Statement: The number of CAUTIs for ICU patients

Included Populations: Infections meeting CDC case definitions of symptomatic
UTI (see Appendix F).

• Other infections of the urinary tract
• CAUTIs present or incubating on admission to the ICU
• CAUTI if the Location of Attribution is a non-ICU location

Data Elements:



• Date of Event
• Device
• Event Type
• Location of Attribution
• Specific Event Type

Denominator Statement: The number of indwelling urinary catheter days for ICU
patients by ICU location.

Included Populations: Patients in adult ICU locations (coronary [medical
cardiac], cardiothoracic, medical, medical-surgical [major teaching hospital/other
hospital], neurosurgical, neurologic, surgical, trauma, burn, and respiratory), and
pediatric ICU locations (burn, cardiothoracic, medical, medical-surgical [major
teaching hospital/other hospital], neurosurgical, respiratory, and surgical).

Excluded Populations: Patients in non-ICU areas

Data Elements:
• Indwelling Urinary Catheter Days
• Location
• Month
• Year

Risk Adjustment: No

Data Collection Approach:
It is recommended that the numerator and denominator data elements be collected
concurrently.

Data Accuracy:
• Health care organizations will need to develop a mechanism for tracking
indwelling urinary catheter days for patients in the ICU if they do not currently
have a process in place.
• The number of patients with an indwelling urinary catheter device is collected
daily, at the same time each day. These daily counts are summed for a monthly
total of urinary catheter days. Data accuracy is enhanced when denominator data
are collected in a consistent manner (e.g., at the same time each day).
• Data accuracy is enhanced when all event definitions are used without
modification. It is recommended that a trained infection control professional (ICP)
collect the numerator data for this measure as some interpretation will be
required. The patient is followed for evidence of infection for 48 hours after
removal of the urinary catheter or for 48 hours after discharge from the ICU,
whichever comes first.
• There is no minimum period of time that the catheter must be in place in order for
the UTI to be considered catheter associated.



• Report only those events that are associated with an eligible reporting location
and are catheter-associated (patient had an indwelling urinary catheter at the
time of or within 48 hours before the onset of the UTI). If a patient has a catheter
inserted on admission to the ICU and develops signs and symptoms of UTI within
the first 48 hours, and there is no evidence of preexisting UTI (e.g., negative lab
values, no signs or symptoms), then if the infection otherwise meets criteria, it
should be called a CAUTI and should be attributed to the ICU.
• For category Adult Major Teaching Hospital MS1; major teaching status is
defined as a hospital that is an important part of the teaching program of a
medical school and the majority of medical students rotate through multiple
clinical services.

Measure Analysis Suggestions: The CAUTI rate per 1,000 urinary catheter-days is
calculated by dividing the number of CAUTIs by the number of catheter-days and
multiplying the result by 1,000. This calculation is performed for the total number of
CAUTI and total number of catheter-days for a hospital-level rate, as well as separately
for each different ICU location.

Facilities may also choose to collect data on non-ICU locations such as medical,
surgical or step down units.

Sampling: No

Data Reported as: Overall aggregate rate for all locations and stratified rates by data
element Location, generated from count data reported as a ratio..

• National Healthcare Safety Network (NHSN) Manual: Patient Safety Component
Protocol. Division of Healthcare Quality Promotion. National Center for Infectious
Diseases, Centers for Disease Control and Prevention. U.S. Department of Health
and Human Services. Atlanta, Georgia 30333. Available at
http://www.cdc.gov/nhsn/.
• Wong ES. Guideline for Prevention of Catheter-associated Urinary Tract Infections.
Infect Control. 1981; 2:126-30.

Centers for Disease Control and Prevention (CDC)






Performance Measure Identifier: NSC-7

Set Measure Performance Measure by ICU Location and Birth weight Category
ID#
NSC-7.1a Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI – All ICU Locations (NSC-7.1b through NSC-7.1t)
NSC-7.1b Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Burn [Burn Critical Care B-Adult]
NSC-7.1c Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Coronary [Medical Cardiac Critical Care MC-
Adult]
NSC –7.1d Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Cardiothoracic [Surgical Cardiothoracic Critical
Care Adult SCT-Adult]
NSC-7.1e Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Medical [Medical Critical Adult M-Adult]
NSC-7.1f Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Medical/Surgical Major Teaching Hospital
[Combined MS – Adult Major Teaching Hospital MS1]
NSC-7.1g Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Medical/Surgical Other Hospital [Combined
MS -Adult Other MS0]
NSC-7.1h Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Neurologic [Neurologic Critical Care N-Adult]
NSC-7.1i Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Neurosurgical [Neurosurgical Critical Care
Adult NS-Adult]
NSC –7.1j Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Respiratory [Respiratory Critical Care R-Adult]
NSC-7.1k Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Surgical [Surgical Critical Care Adult S-Adult]
NSC-7.1l Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Trauma [Trauma Critical Care Adult T-Adult]
NSC-7.1m Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Burn [Burn Critical Care Pediatric, B-Ped]
NSC-7.1n Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Cardiothoracic [Cardiothoracic Critical Care
Pediatric CT-Ped]
NSC-7.1o Intensive Care Unit (ICU) Urinary Catheter-Associated Urinary Tract



Infection CAUTI by Location – Medical [Medical Critical Care Pediatric,
M-Ped]
NSC-7.1p Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Medical-Surgical [Medical – Surgical Critical
Care Pediatric, MS-Ped]
NSC-7.1q Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Neurosurgical [Neurosurgical Critical Care
Pediatric, NS-Ped]
NSC-7.1r Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Respiratory [Respiratory Critical Care Pediatric,
R-Ped]
NSC-7.1s Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Surgical [Surgical Critical Care Pediatric, S-Ped]
NSC-7.1t Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection
CLABSI by Location – Trauma [Trauma Critical Care Pediatric, T-Ped]
NSC-7.2a Neonatal Intensive Care Unit (NICU) Central Line-Associated
Bloodstream Infection CLABSI by all birth weight categories (NSC-
7.2b through NSC-7.2f)
NSC-7.2b Neonatal Intensive Care Unit (NICU) Central Line-Associated
Bloodstream Infection CLABSI by BW ≤750 g
NSC-7.2c Neonatal Intensive Care Unit (NICU) Central Line-Associated
Bloodstream Infection CLABSI by BW 751 – 1,000 g
NSC-7.2d Neonatal Intensive Care Unit (NICU) Central Line-Associated
Bloodstream Infection CLABSI by BW 1,001 – 1,500 g
NSC-7.2e Neonatal Intensive Care Unit (NICU) Central Line-Associated
Bloodstream Infection CLABSI by BW 1,501 – 2,500 g
NSC-7.2f Neonatal Intensive Care Unit (NICU) Central Line-Associated
Bloodstream Infection CLABSI by BW >2,500 g
NSC-7.3a Neonatal Intensive Care Unit (NICU) Umbilical Catheter-Associated
Bloodstream Infection UCABSI by all birth weight categories (NSC-
7.3b through NSC-7.3f)
NSC-7.3b Neonatal Intensive Care Unit (NICU) Umbilical Catheter-Associated
Bloodstream Infection UCABSI by BW ≤750 g
NSC-7.3c Neonatal Intensive Care Unit (NICU) Umbilical Catheter-Associated
Bloodstream Infection UBABSI by BW 751 – 1,000 g
NSC-7.3d Neonatal Intensive Care Unit (NICU) Umbilical Catheter-Associated
Bloodstream Infection UCABSI by BW 1,001 – 1,500 g
NSC-7.3e Neonatal Intensive Care Unit (NICU) Umbilical Catheter-Associated
Bloodstream Infection UCABSI by BW 1,501 – 2,500 g
NSC-7.3f Neonatal Intensive Care Unit (NICU) Umbilical Catheter-Associated
Bloodstream Infection UCABSI by BW >2,500 g

Performance Measure Name: Central Line-Associated Bloodstream Infection Rate for
ICU and NICU patients



Description:
NSC-7.1 The rate of CLABSI for ICU Locations
NSC-7.2 The rate of CLABSI in the NICU Location
NSC-7.3 The rate of UCABSI in the NICU Location

Rationale: Intensive care unit (ICU) and Neonatal Intensive Care Unit (NICU) patients
are at high risk for infections associated with the use of invasive devices. Although
bloodstream infections often occur secondarily to other infections, they may result from
contamination of intravascular catheters or occur spontaneously in immunosuppressed
patients. Critically ill infants have the highest infection rate of all pediatric patients and
one of the most important risk factors for healthcare associated (nosocomial) infections
is birth weight. Infants who weigh < 750 grams at birth are at substantially greater risk of
infection than those who weigh >2,500 grams. Bloodstream infections greatly prolong
hospitalizations and increase resource utilization. Infections are also one of the leading
causes of death in the United States. High rates may suggest the need to examine the
clinical and organizational processes related to the care of patients with central lines,
including adherence to recommended guidelines.



Numerator Statement: The number of CLABSI or UCABSI for ICU or NICU patients



NSC-7.1 NSC-7.2 NSC-7.3
Included • Infections meeting • Infections meeting • Infections meeting CDC
Populations CDC case definitions CDC case definitions case definitions for
for laboratory- for laboratory- laboratory-confirmed
confirmed confirmed bloodstream bloodstream infections
bloodstream infections (LCBI) or (LCBI) or clinical sepsis
infections (LCBI) clinical sepsis (CSEP) (CSEP) (see appendix F)
(see appendix F) (see appendix F) • Infections in patients with
• Infections in patients • Infections in patients an umbilical catheter
with one or more with one or more only
central lines central lines • Infections in patients with
• Infections in patients • Infections in patients in an umbilical catheter and
in eligible adult and NICU location by birth a central line
pediatric ICU weight category: • Infections in patients in
locations. o <750 g NICU location by birth
o 751 – 1,000 g weight category:
o 1,001 – 1,500 g o <750 g
o 1,501 – 2,500 g o 751 – 1,000 g
o >2500 g o 1,001 – 1,500 g
o 1,501 – 2,500 g
o >2500 g
Excluded • Secondary • Secondary • Secondary bloodstream
Populations bloodstream bloodstream infections infections
infections • BSI present or • BSI present or incubating
• BSI present or incubating on on admission to the
incubating on admission to the NICU NICU
admission to the ICU • Infections in patients • Infections in patients with
• Clinical sepsis with an umbilical a central line only
• Infections in patients catheter only • Infections in patients if
if the Location of • Infections in patients the Location of
Attribution is a non- with a central line and Attribution is a non-NICU
ICU location an umbilical catheter location
• Infections in patients if
the Location of
Attribution is a non-
NICU location
Data Date of Event Birth Weight Birth Weight
Elements Device Date of Event Date of Event
Event Type Device Device
Location of Attribution Event Type Event Type
Specific Event Type Specific Event Type Specific Event Type

Denominator Statement: The number of central line days by ICU/NICU, or umbilical
catheter days by NICU



NSC-7.1 NSC-7.2 NSC-7.3
Included • ICU patients by ICU • NICU patients by birth • NICU patients by birth
Populations Locations: coronary, weight category: weight category:
cardiothoracic, o <750 g o <750 g
medical, medical- o 751 – 1,000 g o 751 – 1,000 g
surgical (major o 1,001 – 1,500 g o 1,001 – 1,500 g
teaching hospital/ o 1,501 – 2,500 g o 1,501 – 2,500 g
other hospital), o >2500 g o >2500 g
neurosurgical, • Central line days for • Umbilical catheter days
pediatric, surgical, patients with a central for patients with an
trauma, burn, and line only umbilical catheter only
respiratory. • Patients transferred • Umbilical catheter days
• Any age patient in an from other hospitals for patients with a central
eligible reporting line and an umbilical
location is included catheter in place
• Patients transferred from
other hospitals
Excluded • Central line days for • Central line days for • Umbilical catheter days
Populations patients in non-ICU patients in non-NICU for patients in non-NICU
areas areas areas
• Central line days for • Umbilical catheter days
patients with an for patients with a central
umbilical catheter only line only
• Central line days for
patients with a central
line and an umbilical
catheter
Data Central Line Days- Birth Weight Birth Weight
Elements ICU Central Line Days – Device
Device NICU Location
Location Device Umbilical Catheter Days-
Month Location NICU
Year Month Month
Year Year

Risk Adjustment: No

Data Collection Approach: It is recommended that both the numerator and
denominator data elements be collected concurrently.

Data Accuracy:
• Health care organizations will need to develop a mechanism for tracking central
line days for patients in the ICU and central line/umbilical catheter days for
patients in NICU if they do not currently have a process in place.



• The number of patients with a central line (ICU/NICU) or an umbilical catheter
(NICU) is collected daily, at the same time each day. These daily counts are
summed for a monthly total of central line or umbilical catheter days. Data
accuracy is enhanced when denominator data are collected in a consistent
modification. It is recommended that a trained infection control professional (ICP)
collect the numerator data for this measure as some interpretation will be
required. The ICU patient is followed for evidence of infection for 48 hours after
the removal of the central line or for 48 hours after discharge from the ICU. The
NICU patient is followed for evidence of infection for 48 hours after the removal
of the central line/umbilical catheter or for 48 hours after discharge from the
NICU.
• Report only those events that are associated with an eligible reporting location
and are central line/umbilical catheter-associated (patient had a central line
and/or an umbilical catheter at the time of or within 48 hours before the onset of
the BSI).
• NICU patients with both a central line and an umbilical catheter in place on a
given day are counted as one umbilical catheter day.
• ICU/NICU patients with more than one central line in place on a given day are
counted as one central line day.
• For category Adult Major Teaching Hospital MS1; major teaching status is
defined as a hospital that is an important part of the teaching program of a
clinical services.

• For ICU locations: The CLABSI rate per 1,000 central line days is calculated by
dividing the number of CLABSIs by the number of central line days and
multiplying the result by 1,000. This calculation is performed for the total number
of CLABSIs and total number of central line days for a hospital-level rate, as well
as separately for the different adult ICU locations.
• For NICU location: The CLABSI rate per 1,000 central line days is calculated by
dividing the number of CLABSIs by the number of central line days and
multiplying the result by 1,000. This calculation is performed for the total number
of CLABSIs and total number of central line days for a hospital-level rate, as well
as separately for the different NICU locations and birth weight categories.
• For NICU location: The UCABSI rate per 1,000 umbilical catheter days is
calculated by dividing the number of UCABSIs by the number of umbilical
catheter days and multiplying the result by 1,000. This calculation is performed
for the total number of UCABSIs and total number of central line days for a
hospital-level rate, as well as separately for the different NICU locations and birth
weight categories.
• Facilities may also choose to collect data on non-ICU locations such as medical,
surgical or step down units.



Sampling: No.

elements Location and Birth Weight, generated from count data reported as a ratio.

• CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections.
Morbidity and Mortality Weekly Report. August 9, 2002. Vol. 51. Ro.RR-10.
Available online http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html.
• Gaynes RP, Solomon S. Improving hospital-acquired infection rates: the CDC
experience. JCAHO J Qual Improv 1996; 22:457-67.
http://www.cdc.gov/nhsn/








Set Measure Performance Measure by ICU Location and Birth weight Category
ID#
NSC-8.1a Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP – All
ICU Locations (NSC-8.1b through NSC-8.1t)
NSC-8.1b Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Burn [Burn Critical Care B-Adult]
NSC-8.1c Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Coronary [Medical Cardiac Critical Care MC- Adult]
NSC-8.1d Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Cardiothoracic [Surgical Cardiothoracic Critical Care Adult
SCT-Adult]
NSC-8.1e Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Medical [Medical Critical Adult M-Adult]
NSC-8.1f Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Medical/Surgical Major Teaching Hospital [Combined MS
– Adult Major Teaching Hospital MS1]
NSC-8.1g Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Medical/Surgical Other Hospital [Combined MS -Adult
Other MS0]
NSC-8.1h Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Neurologic [Neurologic Critical Care N-Adult]
NSC-8.1i Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Neurosurgical [Neurosurgical Critical Care Adult NS-Adult]
NSC-8.1j Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Respiratory [Respiratory Critical Care R-Adult]
NSC-8.1k Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Surgical [Surgical Critical Care Adult S-Adult]
NSC-8.1l Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Trauma [Trauma Critical Care Adult T-Adult]
NSC-8.1m Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Burn [Burn Critical Care Pediatric, B-Ped]
NSC-8.1n Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Cardiothoracic [Cardiothoracic Critical Care Pediatric CT-
Ped]
NSC-8.1o Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Medical [Medical Critical Care Pediatric, M-Ped]



NSC-8.1p Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Medical-Surgical [Medical – Surgical Critical Care Pediatric,
MS-Ped]
NSC-8.1q Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Neurosurgical [Neurosurgical Critical Care Pediatric, NS-
Ped]
NSC-8.1r Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Respiratory [Respiratory Critical Care Pediatric, R-Ped]
NSC-8.1s Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Surgical [Surgical Critical Care Pediatric, S-Ped]
NSC-8.1t Intensive Care Unit (ICU) Ventilator-Associated Pneumonia VAP by
Location – Trauma [Trauma Critical Care Pediatric, T-Ped]
NSC-8.2a Neonatal Intensive Care Unit (NICU) Ventilator-Associated Pneumonia
VAP by all birth weight categories (NSC-8.2b through NSC-8.2f)
NSC-8.2b Neonatal Intensive Care Unit (NICU) Ventilator-Associated Pneumonia
VAP by BW ≤750 g
NSC-8.2c Neonatal Intensive Care Unit (NICU) Ventilator-Associated Pneumonia
VAP by BW 751 – 1,000 g
NSC-8.2d Neonatal Intensive Care Unit (NICU) Ventilator-Associated Pneumonia
VAP by BW 1,001 – 1,500 g
NSC-8.2e Neonatal Intensive Care Unit (NICU) Ventilator-Associated Pneumonia
VAP by BW 1,501 – 2,500 g
NSC-8.2f Neonatal Intensive Care Unit (NICU) Ventilator-Associated Pneumonia
VAP by BW >2,500 g

Performance Measure Name: Ventilator-Associated Pneumonia Rate for ICU and
NICU patients

Description:
NSC-8.1 The rate of VAPs for ICU Locations
NSC-8.2 The rate of VAPs for NICU Locations

Rationale:
Pneumonia is the second most common healthcare associated (nosocomial) infection in
the United States and is associated with substantial morbidity and mortality. Patients
with mechanically-assisted ventilation have a high risk of developing health-care
associated pneumonia. Prevention and control of health-care associated pneumonia is
discussed in the CDC Guidelines for Preventing Health-Care-Associated Pneumonia.
The Guideline strongly recommends that surveillance be conducted for bacterial
pneumonia in ICU patients who are mechanically ventilated to facilitate the identification
of trends and comparative analysis. High rates may suggest the need to examine the
clinical and organizational processes related to the care of patients on ventilators
including adherence to recommended guidelines.




Improvement Noted: A decrease in the rate.

Numerator Statement: The number of VAPs for ICU or NICU patients

NSC-8.1 NSC-8.2
Included Pneumonia meeting the CDC Pneumonia meeting the CDC
Populations case definitions (see case definitions (see Appendix
Appendix F) F)
Excluded • Pneumonia present or • Pneumonia present or
Populations incubating on admission to incubating on admission to
the ICU the NICU
• Infections in patients if the • Pneumonia in neonates in
Location of Attribution is a non-NICU areas
non-ICU location • Infections in neonates if the
• Pneumonia in patients in Location of Attribution is a
non-ICU areas non-NICU location
Data Elements Date of Event Birth Weight
Device Date of Event
Event Type Device
Location of Attribution Event Type
Specific Event Type Location of Attribution
Specific Event Type

Denominator Statement: The number of ventilator days by ICU/NICU

NSC-8.1 NSC-8.2
Included ICU patients by ICU location: NICU neonates by birth weight
Populations coronary, cardiothoracic, category:
medical, medical-surgical < 750 g;
(major teaching hospital/other 751-1,000 g;
hospital), neurosurgical, 1,001-1,500 g;
pediatric, surgical, trauma, 1,501- 2,500 g;
burn, and respiratory. Any >2,500 g.
age patient in an eligible
reporting location is included.
Excluded Patients in non-ICU locations Neonates in non-NICU
Populations locations
Data Elements Location Birth Weight
Month Location
Ventilator Days Month
Year Ventilator Days
Year

Risk Adjustment: No



Data Collection Approach: It is recommended that the numerator and denominator
data elements be collected concurrently.

Data Accuracy:
• Health care organizations will need to develop a mechanism for tracking
ventilator days for patients in the ICU/NICU if they do not currently have a
process in place.
• The number of patients with a ventilator is collected daily, at the same time each
day. These daily counts are summed for a monthly total of ventilator days. Data
accuracy is enhanced when denominator data are collected in a consistent
modification (e.g., at the same time each day). It is recommended that a trained
infection control professional (ICP) collect the numerator data for this measure as
some interpretation will be required. The ICU patient is followed for evidence of
infection for 48 hours after the removal from the ventilator or for 48 hours after
discharge from the ICU.
• There is no minimum period of time that the ventilator must be in place in order
for the PNEU to be considered ventilator-associated.
• Report only those events that are associated with the nursing care area where
the patient was assigned when the infection was acquired and are ventilator-
associated (patient was intubated and ventilated at the time of or within 48 hours
before the onset of the event).
• Lung expansion devices such as intermittent positive pressure breathing (IPPB);
nasal positive end-expiratory pressure (PEEP), and continuous nasal positive
airway pressure (CPAP, hypo CPAP) are not considered ventilators unless
delivered via tracheostomy or endotracheal intubation (e.g., ET-CPAP).
• There is a hierarchy of specific categories within the major site pneumonia. Even
if a patient meets criteria for more than one specific site, report only one:
o If a patient meets criteria for both PNU1 and PNU2, report PNU2
• Report concurrent lower respiratory tract infection (e.g., abscess or emphysema)
and pneumonia with the same organism(s) as pneumonia.
• For category NSC-8f Adult Major Teaching Hospital MS1; major teaching status
is defined as a hospital that is an important part of the teaching program of a
clinical services.

• For ICU Locations: The VAP rate per 1,000 ventilator-days is calculated by
dividing the number of VAPs by the number of ventilator-days and multiplying the
result by 1,000. This calculation is performed for the total number of VAPs and
total number of ventilator-days for a hospital-level rate, as well as separately for
the different ICU location.



• For NICU Locations: The VAP rate per 1,000 ventilator-days is calculated by
dividing the number of VAPs by the number of ventilator-days and multiplying the
result by 1,000. This calculation is performed for the total number of VAPs and
total number of ventilator-days for a hospital-level rate, as well as separately for
the different NICU locations and birth weight categories.
• Facilities may also choose to collect data on non-ICU locations where patients
are ventilated such as medical, surgical or step down units.

Sampling: No

elements Location and Birth Weight, generated from count data reported as a ratio.

• CDC Guidelines for Preventing Health-Care-Associated Pneumonia, 2003.
Available at
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CDCpneumo_guidelines.pdf.
• Emori TG, Edwards JR, Culver DH, Sartor C, Stroud LA, Gaunt EE, Horan TC,
Gaynes RP. Accuracy of reporting nosocomial infections in intensive care unit
patients to the National Nosocomial Infections Surveillance System: a pilot study.
Infect Control Hosp Epidemiol. 1998; 19:308-316.
• Matthews PJ, Mathews LM. Reducing the risks of ventilator-associated infections.
Dimens Crit Care Nurs. 2000; 19(1):18-21.




NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR NURSING-
SENSITIVE CARE PERFORMANCE MEASURES



Set Measure ID# Performance Measure Name
NSC-9.1b Nursing hours worked by RNs by Type of Unit – Critical Care -
adult
NSC-9.1c Nursing hours worked by RNs by Type of Unit – Step-down - adult
NSC-9.1d Nursing hours worked by RNs by Type of Unit – Medical - adult
NSC-9.1e Nursing hours worked by RNs by Type of Unit – Surgical - adult
NSC-9.1f Nursing hours worked by RNs by Type of Unit – Med-Surg
Combined - adult
NSC-9.1g Nursing hours worked by RNs by Type of Unit – Mixed Acuity -
adult
NSC-9.2b Nursing hours worked by LPNs/LVNs by Type of Unit - Critical
Care - adult
NSC-9.2c Nursing hours worked by LPNs/LVNs by Type of Unit – Step-down
- adult
NSC-9.2d Nursing hours worked by LPNs/LVNsby Type of Unit – Medical -
adult
NSC-9.2e Nursing hours worked by LPNs/LVNs by Type of Unit – Surgical -
adult
NSC-9.2f Nursing hours worked by LPNs/LVNs Type of Unit - Med-Surg
Combined - adult
NSC-9.2g Nursing hours worked by LPNs/LVNs Type of Unit – Mixed Acuity
- adult
NSC-9.3b Nursing hours worked by UAPs Type of Unit - Critical Care - adult
NSC-9.3c Nursing hours worked by UAPs Type of Unit – Step-down - adult
NSC-9.3d Nursing hours worked by UAPs Type of Unit – Medical - adult
NSC-9.3e Nursing hours worked by UAPs Type of Unit – Surgical - adult
NSC-9.3f Nursing hours worked by UAPs Type of Unit - Med-Surg
Combined - adult
NSC-9.3g Nursing hours worked by UAPs Type of Unit - Mixed Acuity –
adult
NSC-9.4b Nursing hours worked by Contract staff (RN, LPN/LVN, and UAP)
by Type of Unit - Critical Care - adult
NSC-9.4c Nursing hours worked by Contract staff (RN, LPN/LVN, and UAP)
by Type of Unit – Step-down - adult
NSC-9.4d Nursing hours worked by Contract staff (RN, LPN/LVN, and UAP)
by Type of Unit – Medical - adult
NSC-9.4e Nursing hours worked by Contract staff (RN, LPN/LVN, and UAP)
by Type of Unit – Surgical - adult



NSC-9.4f Nursing hours worked by Contract staff (RN, LPN/LVN, and UAP)
by Type of Unit - Med-Surg Combined - adult
NSC-9.4g Nursing hours worked by Contract staff (RN, LPN/LVN, and UAP)
by Type of Unit – Mixed Acuity - adult

Performance Measure Name: Skill Mix

Description:
NSC-9.1 Percentage of productive nursing hours worked by RN staff (employee
and contract) with direct patient care responsibilities
NSC-9.2 Percentage of productive nursing hours worked by LPN/LVN staff
(employee and contract) with direct patient care responsibilities
NSC-9.3 Percentage of productive nursing hours worked by UAP staff (employee
and contract) with direct patient care responsibilities
NSC-9.4 Percentage of productive nursing hours worked by contract staff (RN,
LPN/LVN, and UAP) with direct patient care responsibilities

Rationale: The skill mix of the nursing staff, typically expressed as the proportion of
RNs, LPNs/LVNs and UAPs to total nursing hours has been widely studied with respect
to its effects on the quality of care. If the percentage of hours supplied by RNs is not
adequate, less skilled staff may have to perform tasks for which they are not trained,
thus increasing the risk of adverse patient outcomes. Examining the relationship
between skill mix and processes and outcomes of care within health care organizations
may identify opportunities to improve care delivery, patient outcomes, and provide an
evidence base for determining the most effective mixture of staffing.

Type of Measure: Structure

Improvement Noted as: Either an increase or a decrease in the rate depending on the
context of the measure

Numerator Statement: Number of productive hours worked by licensure level and
employment status.



NSC-9.1 NSC-9.2 NSC-9.3 NSC-9.4
Included Productive Productive Productive hours Productive hours
Popula- hours worked hours worked worked by worked by contract
tions by RN staff by LPN/LVN unlicensed staff (RN, LPN/LVN,
with direct staff with direct assistive and UAP) with
patient care patient care personnel (UAP) direct patient care
responsibilities responsibilities staff with direct responsibilities for
for greater than for greater than patient care greater than 50% of
50% of their 50% of their responsibilities their shift. Include:
shift. Include: shift. Include: for greater than • Staff not employed
• Staff who are • Staff who are 50% of their by your facility
counted in counted in the shift. Include: • Staff hired on a
the staffing staffing • Staff who are contractual basis
matrix, and matrix, and counted in the to fill staffing
• Who are • Who are staffing matrix, needs for a
replaced if replaced if and designated shift or
they call in they call in • Who are on another short-
sick, and sick., and replaced if they term basis
• Work hours • Work hours call in sick, and • Registry staff from
are charged are charged to • Work hours are outside the facility
to the unit’s the unit’s cost charged to the (e.g., not floating
cost center center unit’s cost staff from within
• Contract staff • Contract staff center the facility)
• Contract staff • Traveling nurse
staff contracted to
the facility for a
designated period
of time
Excluded • Persons • Persons • Persons whose • Persons whose
Popula- whose whose primary primary primary
tions primary responsibility responsibility is responsibility is
responsibility is administrative administrative in
is administrative in nature nature
administrativ in nature • Unit secretary, • Specialty teams,
e in nature • Specialty monitor techs, patient educators
• Specialty teams, patient therapy or case managers
teams, educators or assistants, who are not
patient case student nurses assigned to a
educators or managers fulfilling specific unit.
case who are not education
managers assigned to a requirements,
who are not specific unit. and sitters not
assigned to a providing
specific unit. typical UAP
activities



NSC-9.1 NSC-9.2 NSC-9.3 NSC-9.4
Data Month LPN/ LVN Month LPN/LVN Hours
Elements RN Hours Hours UAP Hours [Contract/Agency]
[Contract/ [Contract/ [Contract/ Month
Agency] Agency] Agency] RN Hours
RN Hours LPN and LVN UAP Hours [Contract/Agency]
[Employee] Hours [Employee] UAP Hours
Type of Unit [Employee] Type of Unit [Contract/Agency]
Year Month Type of Year Type of Unit
Unit Year
Year

Denominator Statement: Total number of productive hours worked by nursing staff
[RN, LPN/LVN, UAP (employee and contract)] with direct patient care responsibilities
during the calendar month.

Included Populations: Productive hours worked by nursing staff with direct
patient care responsibilities on adult critical care, step-down, medical-surgical,
and mixed acuity units

Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, etc)

Data Elements:
• LPN/LVN Hours [Contract/Agency]
• LPN/LVN Hours [Employee]
• Month
• RN Hours [Contract/Agency]
• RN Hours [Employee ]
• Type of Unit
• UAP Hours [Contract/Agency]
• UAP Hours [Employee]
• Year

Risk Adjustment: No

Data Collection Approach: Retrospective

Data Accuracy:
• Payroll or staffing records should be audited to remove non-direct care hours
(education, sick leave, vacation leave etc.)
• An eligible reporting unit will calculate nursing care hours data by calendar
month.
• If the hospital does not have monthly staffing records for pay periods that go
across two months, the hospital should divide the total hours by 14 to get
average daily hours, then multiply by the number of days that belong to each
month. See Appendix D, Table 5.



• Make sure ineligible staff hours are not included (e.g., unit secretary, monitor
techs, therapy assistants, student nurses fulfilling education requirements, and
sitters not providing typical UAP activities)
• Unlicensed Assistive Personnel (UAP) are individuals trained to function in an
assistive role to nurses in the provision of patient care, as delegated by and
under the supervision of the registered nurse. In some states assistive nursing
personnel may be licensed. For the purposes of this performance measure set,
include these persons in the UAP category for calculation.


Sampling: No

Data Reported as: Aggregate rate generated from count data as a proportion.

• Blegan, M.A., Vaughn, & Vojir, C.P. (2007). Nurse staffing levels: Impact of
organizational characteristics and registered nurse supply. Health Services
Research, 42(5), 1822-1848.
• Klaus, et al. (2008). Reliability of the Nursing Care Hour Measure. (Presentation)
Council for the Advancement of Nursing Science, 2008 State of the Science
Congress on Nursing Research, Washington, D.C, October 2, 2008
• Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002).
Nurse-staffing levels and the quality of care in hospitals. The New England Journal
of Medicine, 346(22), 1715-1723.
Patient Outcomes in Hospitals. HRSA Report No. 230-99-0021; February 18, 2001.
• Sales, A., Sharp, N., Li, Y., Lowy, E., Greiner, G., Liu, C., Alt-White, A., Cathy, R.,
Sochalski, J., Stetler, C., Cournoyer, P., & Needleman, J. (2008). The association
between nursing factors and patient mortality in the Veterans Health Administration:
The view from the nursing unit level. Medical Care, 46(9), 938-945.

Performance Measure Source / Developer: American Nurses Association (ANA) –
National Database for Nursing Quality Indicators (NDNQI)






NSC-10.1b Hours per patient day worked by RNs by Type of Unit – Critical
Care - adult
NSC-10.1c Hours per patient day worked by RNs by Type of Unit – Step-down
- adult
NSC-10.1d Hours per patient day worked by RNs by Type of Unit – Medical -
adult
NSC-10.1e Hours per patient day worked by RNs by Type of Unit – Surgical -
adult
NSC-10.1f Hours per patient day worked by RNs by Type of Unit – Med-Surg
Combined - adult
NSC-10.1g Hours per patient day worked by RNs by Type of Unit – Mixed
Acuity - adult
NSC-10.2b Hours per patient day worked by nursing staff (RN, LPN/LVN, and
UAP) by Type of Unit – Critical Care - adult
NSC-10.2c Hours per patient day worked by nursing staff (RN, LPN/LVN, and
UAP) by Type of Unit – Step-down - adult
NSC-10.2d Hours per patient day worked by nursing staff (RN, LPN/LVN, and
UAP) by Type of Unit – Medical - adult
NSC-10.2e Hours per patient day worked by nursing staff (RN, LPN/LVN, and
UAP) by Type of Unit – Surgical - adult
NSC-10.2f Hours per patient day worked by nursing staff (RN, LPN/LVN, and
UAP) by Type of Unit – Med-Surg Combined - adult
NSC-10.2g Hours per patient day worked by nursing staff (RN, LPN/LVN, and
UAP) by Type of Unit – Mixed Acuity - adult

Performance Measure Name: Nursing care hours per patient day

Description:
NSC-10.1 The number of productive hours worked by RNs with direct patient care
responsibilities per patient day.
NSC-10.2 The number of productive hours worked by nursing staff (RN, LPN/LVN,
and UAP) with direct patient care responsibilities per patient day.

Rationale: Nursing care hours per patient day measures the supply of nursing relative
to the patient workload. The relationship of nurse staffing to the quality of patient care
and patient outcomes has been the subject of multiple research studies in recent years.
The total number of nursing care hours per patient day reflects time constraints on



nursing staff that can constrain quality of care, resulting in nurses being stressed,
fatigued or distracted, increasing the risk for mistakes or omissions in care. Examining
the relationship between nursing care hours, and processes and outcomes of care
within health care organizations, may identify opportunities to improve care delivery,
patient outcomes, and provide an evidence base for determining the most effective
staffing levels.


Improvement Noted as: Either an increase or a decrease in the rate depending on the
context of the measure.

Numerator Statement: Total number of productive hours worked by nursing staff with
direct patient care responsibilities during the calendar month.

NSC-10.1 NSC-10.2
Included Productive hours worked by RN Productive hours worked by
Populations staff with direct patient care nursing staff (RN, LVN/LPN, and
responsibilities for greater than UAP) with direct patient care
50% of their shift. Include: responsibilities for greater than
• Staff who are counted in the 50% of their shift. Include:
staffing matrix, and • Staff who are counted in the
• Who are replaced if they call in staffing matrix, and
sick., and • Who are replaced if they call in
• Work hours are charged to the sick., and
unit’s cost center • Work hours are charged to the
• Contract staff unit’s cost center
• Contract staff
Excluded • Persons whose primary • RNs whose primary responsibility
Populations responsibility is administrative is administrative in nature
in nature • Specialty teams, patient
• Specialty teams, patient educators or case managers who
educators or case managers are not assigned to a specific
who are not assigned to a unit.
specific unit. • Unit clerks, monitor techs, and
others with no direct patient care
responsibilities
Data Elements Month LPN/LVN Hours [Contract/Agency]
RN Hours [Contract/Agency] LPN/LVN Hours [Employee ]
RN Hours [Employee] Month
Type of Unit RN Hours [Contract/Agency]
Year RN Hours [Employee]
Type of Unit
Year



Denominator Statement: Patient days by Type of Unit during the calendar month

NSC-10.1 NSC-10.2
Included All patients – inpatient, short stay All patients – inpatient, short stay
Populations patients, observation patients patients, observation patients and
and same day surgery patients - same day surgery patients - who
who receive care on an eligible receive care on an eligible
reporting unit for all or part of a reporting unit for all or part of a
day. day.
Adult medical, surgical, medical- Adult medical, surgical, medical-
surgical combined, critical care, surgical combined, critical care,
step-down, and mixed acuity step-down, and mixed acuity units.
units.
Excluded Other unit types (e.g., pediatric, Other unit types (e.g., pediatric,
Populations obstetrical, rehab, etc) obstetrical, rehab, etc)
Data Elements Month Month
Patient Days Patient Days
Type of Unit Type of Unit
Year Year

Risk Adjustment: No

Data Collection Approach: Retrospective from payroll or staffing records and patient
census records

Data Accuracy:
• Payroll or staffing records should be audited to remove non-direct care hours
(education, sick leave, vacation leave etc.) and to ensure that ineligible staff are
not included (e.g., unit secretary, monitor techs).
• An eligible reporting unit will calculate nursing care hour’s data by calendar
month.
• If the hospital does not have monthly staffing records for pay periods that go
across two months, the hospital should divide the total hours by 14 to get
average daily hours, then multiply by the number of days that belong to each
month. See Appendix D, Table 5.
• Each unit that reports hours data, must also collect patient day data for the same
month (as outlined in the data element, Patient Days – also see Appendix D:
Table Patient Day Reporting Methods) in order to calculate ratio.




Sampling: No

Data Reported as: Aggregate rate generated from count data as a ratio.

• Blegan, M.A., Vaughn, & Vojir, C.P. (2007). Nurse staffing levels: Impact of
organizational characteristics and registered nurse supply. Health Services
Research, 42(5), 1822-1848.
• Klaus, et al. (2008). Reliability of the Nursing Care Hour Measure. (Presentation)
Council for the Advancement of Nursing Science, 2008 State of the Science
Congress on Nursing Research, Washington, D.C, October 2, 2008
• Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002).
Nurse-staffing levels and the quality of care in hospitals. The New England Journal
of Medicine, 346(22), 1715-1723.
Patient Outcomes in Hospitals. HRSA Report No. 230-99-0021; February 18, 2001.
• Sales, A., Sharp, N., Li, Y., Lowy, E., Greiner, G., Liu, C., Alt-White, A., Cathy, R.,
Sochalski, J., Stetler, C., Cournoyer, P., & Needleman, J. (2008). The association
between nursing factors and patient mortality in the Veterans Health Administration:
The view from the nursing unit level. Medical Care, 46(9), 938-945.

(NDNQI)






NSC-11.1 Voluntary turnover for Registered Nurse (RN) and Advanced
Practice Nurse (APN)
NSC-11.2 Voluntary turnover for Licensed Practical Nurse
(LPN)/Licensed Vocational Nurse (LVN)
NSC-11.3 Voluntary turnover for Unlicensed Assistive Personnel (UAP)

Performance Measure Name: Voluntary Turnover

Description:
NSC-11.1 Total number of full-time and part-time RN and APN voluntary
uncontrolled separations occurring during the calendar month
NSC-11.2 Total number of full-time and part-time LPN, LVN voluntary uncontrolled
separations occurring during the calendar month
NSC-11.3 Total number of full-time and part-time UAP voluntary uncontrolled
separations occurring during the calendar month

Rationale: Voluntary turnover within an organization that is due primarily to employee
dissatisfaction with their job (including aspects such as compensation, work
environment, team members, or management) and excluding other recognized causes
of separation such as relocation, retirement or termination is a widely recognized and
highly specific, and more accurate measure for assessing employee separations than
total turnover rate. It is correlated with levels of employee satisfaction and impacts the
stability of staffing resources. Furthermore, with high patient to nurse ratios, nurses are
more likely to experience increased emotional exhaustion (Aiken, et al.). Shortages of
available hospital nurses make staff satisfaction and retention an even more critical
issue for hospitals. Collection of voluntary turnover information allows healthcare
organizations to focus on separations that are likely related to dissatisfaction. By
assessing this important workforce issue, an organization may identify opportunities to
improve job satisfaction, increase staff retention and maximize nursing resources.


Improvement Noted as: A decrease in rate

Numerator Statement: The total number of voluntary uncontrolled separations during
the calendar month.



NSC-11.1 NSC-11.2 NSC-11.3
Included RN and APN LPN/LVN separations UAP separations
Populations separations
Excluded • Transfers within the • Transfers within the • Transfers within the
Populations organization. organization organization
• Separations due to • Separations due to • Separations due to
death, disability, death, disability, death, disability,
illness, relocation, illness, relocation, illness, relocation,
military service, military service, military service,
education, education, education,
retirement, retirement, retirement,
promotions, promotions, promotions,
performance or performance or performance or
discipline. discipline. discipline.
• Cutbacks due to • Cutbacks due to • Cutbacks due to
mergers, cyclical mergers, cyclical mergers, cyclical
layoffs, or other layoffs, or other layoffs, or other
permanent reduction permanent reduction permanent reduction
in force. in force. in force.
Data Month Month Month
Elements Reason for Separation Reason for Separation Reason for Separation
Separations APN Separation LPN/LVN Separations UAP
Separations RN Type of Unit Type of Unit
Type of Unit Year Year
Year

Denominator Statement: Total number of full time and part time employees on the last
day of the month.



NSC-11.1 NSC-11.2 NSC-11.3
Included • RNs and APNs • LPNs/LVNs engaged • UAP engaged in
Populations engaged in direct in direct patient care direct patient care
patient care positions positions, employed positions, employed
or related nursing on the last day of the on the last day of
supervisory positions month. the month.
and positions for • Full-time and part- • Full-time and part-
which an RN degree time staff employed time staff employed
is a specific condition by the hospital but by the hospital but
of hire, employed on who have no regular who have no
the last day of the schedule or unit regular schedule or
month. (e.g., float pool). unit (e.g., float
• Full-time and part- pool).
time staff employed
by the hospital but
who have no regular
schedule or unit (e.g.,
float pool).
Excluded • PRN/Per diems, • PRN/Per diems, PRN/Per diems,
Populations contractors, contractors, contractors,
consultants, consultants, consultants,
temporary agency, temporary agency, temporary agency,
travelers, students, or travelers, students, travelers, students,
other non-permanent or other non- or other non-
employees. permanent permanent
employees. employees.
Data Employed APNs Employed LPNs/LVNs Employed UAP
Elements Employed RNs Month Month
Month Type of Unit Type of Unit
Type of Unit Year Year
Year

Risk Adjustment: No

Data Collection Approach: Retrospective

Data Accuracy:
1) RNs refers to nursing positions that require an RN or higher nursing degree for
hire; generally these are direct patient care positions or related nursing
supervisory positions; therefore a Director of Finance position that happens to be
filled by an individual with an RN degree would not be included in this calculation
unless the RN degree was a specific condition of hire.
2) Make sure all non-permanent employees, e.g. contractors, consultants,
temporary agency or travelers are excluded from the denominator and
numerator.



3) Make sure all applicable voluntary uncontrolled exclusions have been applied in
the numerator.
4) Promotions are excluded from the numerator.
5) Make sure only applicable groups are included (i.e., RN/APN)
6) Separation is based on last day worked. For example if an eligible employee
gave notice on March 25 but the last day worked was April 15 – the separation
would be credited to the month of April and the second quarter of the year.

Measure data on separations and employee numbers are collected by Type of Unit to
allow for internal hospital analysis and quality improvement initiatives. Although
collected at the unit level the measures rates are publicly reported at the hospital level.


Sampling: No

Data Reported as: Aggregate rate generated from count data reported as a ratio


• Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing
and patient mortality, nurse burnout, and job satisfaction. JAMA, 2002; 288:1987-
1993.
• Aiken LH, Sochalski J, Anderson GF, Downsizing the hospital nursing workforce.
Health Aff. 1996; 15:88-92.
• Buerhaus PI. Shortages of hospital registered nurses: causes and perspectives on
public and private sector actions. Nurs Outlook. 2002; 50:4-6
• Buerhaus PI, Needleman J, Mattke S, Steweard M. Strengthening hospital nursing.
Health Aff. 2002; 21:123-132.
• Buerhaus PI, Staiger DO, Auerbach DI. Implications of an aging registered nurse
workforce. JAMA. 2000; 283:2948-2954.
• Kosel KC, Olivo T. VHA’s 2002 Research Series: The Business Case for Work
Force Stability. Voluntary Hospitals of America; April 2002.
• Lake ET. Advances in understanding and predicting nurse turnover. Research in the
Sociology of Health Care. 1998; 15:147-171.
• Mark BA, Sayler J, Smith CS. A theoretical model for nursing systems outcomes
research. Nurs Admin Q. 1996; 20:12-27.
• McClure ML, Hinshaw AS, eds. Magnet Hospitals Revisited: Attraction and
Retention of Professional Nurses. Washington, DC: American Nurses Publishing;
2002.
• Needleman J, Buerhaus P, Mattke S, Steward M, Zelevinsky K. Nurse-staffing
levels and the quality of care in hospitals. N Eng J Med. 2002; 346:1715-1722.



• Taunton RL, Kleinbeck SV, Stafford R, Woods CQ, Bott MJ. Patient outcomes: are
they linked to registered nurse absenteeism, separation, or workload? J Nurs
Admin. 1994(24):48-55.

VHA Inc.






NSC-12a Mean score on a composite of all subscale scores
NSC-12b Mean score on Nurse Participation in Hospital Affairs
NSC-12c Mean score on Nursing Foundations for Quality of Care
NSC-12d Mean score on Nurse Manager Ability, Leadership, and Support of
Nurses
NSC-12e Mean score on Staffing and Resource Adequacy
NSC-12f Mean score on Collegial Nurse-Physician Relations
NSC-12g Three category variable indicating favorable, mixed, or unfavorable
practice environments

Performance Measure Name: Practice Environment Scale-Nursing Work Index (PES-
NWI)

Description: The mean scores on index subscales and a composite mean of all
subscale scores based on surveys completed by Registered Nurses (RNs).

Rationale: Nurses provide the majority of primary patient care in the hospital setting.
Research has increasingly demonstrated the positive impact of nursing on the quality of
patient care processes and outcomes. The practice environment has been shown to
influence successful recruitment and retention of nurses. By measuring the practice
environment, health care organizations may identify opportunities to facilitate
professional nursing practice, and enhance the quality of patient care processes and
outcomes.
40 publications in peer-reviewed U.S. and international journals document the ongoing
psychometric rigor of the PES-NWI, its link to patient and nurse outcomes, and its
dissemination worldwide to measure and improve nurse's practice environments.
Twenty-nine studies have been conducted to evaluate the association of the practice
environment, as measured by the PES-NWI, with patient and nurse outcomes, quality of
care, or for other descriptive purposes.
Several studies have shown that patients in hospitals with better care environments as
measured by the PES-NWI patients had significantly lower risks of death and failure to
rescue (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Friese, Lake, Aiken, Silber, &
Sochalski, 2008). Aiken et al. used 1999 data from 10,184 nurses and 232,342 general
surgical patients in 168 Pennsylvania hospitals and found that the likelihood of patients
dying within 30 days of admission was 14% lower in hospitals with better care
environments than in hospitals with poor care environments. Friese et al. studied



surgical oncology patients and found that patients in hospitals with unfavorable practice
environments had 37% greater odds of dying within 30 days and 48% higher odds of
failure to rescue than patients in hospitals with favorable practice environments.
Gardner, Thomas-Hawkins, Fogg & Latham (2007) found that kidney dialysis facilities
with more favorable PES-NWI ratings had lower rates of patient hospitalizations.
Researchers focus on patient satisfaction as a key outcome of nursing care. Kutney-
Lee et al. (in press) studied 430 hospitals in four states and found that hospitals with
better nurse practice environments had higher patient satisfaction scores, as measured
with 2006-2007 Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) survey Medicare data.
Many studies provide evidence that differences in practice environments as measured
by the PES-NWI are associated with differences in nurse burnout, satisfaction, intent to
leave, turnover, needlestick injuries, empowerment, and work-related disability
(Bruyneel, et al., in press; Clarke, Sloane, & Aiken, 2002; Friese, 2005; Gunnarsdóttir,
et al., in press; Kanai-Pak, et al., 2007; Laschinger, Almost, & Tuer-Hodes, 2003;
Laschinger, et al., 2001; Leiter & Laschinger, 2006; Manojlovich, 2005; Manojlovich &
Laschinger, 2007; O'Brien-Pallas, et al., 2004 ; Shamian, Kerr, Laschinger, & Thomson,
2002; Thomas-Hawkins, Denno, Currier, & Wick, 2003; Vahey, et al., 2004; Wade, et
al., 2008). These studies include data sets spanning the period 1999 to 2008 and
comprising large samples of nurses and hospitals in the U.S., Canada, Iceland, and
Japan.
The PES-NWI has been used extensively (39 publications) in a brief period to evaluate
its instrument performance in a variety of locations internationally and to test the links
between nurses’ environments and nurse and patient outcomes. The evidence from the
literature supports the psychometric rigor of the instrument and suggests that nurses’
practice environments are part of a causal chain linking nursing care to nurse and
patient outcomes. The evidence linking practice environments to nurse outcomes is
sizable, comprising 15 studies. The evidence on patient outcomes is small but growing:
of eight studies that linked PES-NWI ratings to patient outcomes, six of the eight were
published since 2007. Six of the eight patient outcomes studies identified statistically
significant findings, one had significant bivariate but not multivariate associations, and
the eighth had nonsignificant findings associated with the practice environment in a
sample of 25 intensive care units. A third type of outcome that has been studied is
nurse-rated quality of care and adverse event frequency. Eight of these ten studies
identified statistically significant associations between practice environment ratings and
nurse-assessed quality of care or adverse events; two did not.
Source: Eileen Lake


Improvement Noted as: An increase in the mean score

Continuous Variable Statement: For surveys completed by Registered Nurses (RN).
See Appendix G:
12a) Mean score on a composite of all subscale scores
12b) Mean score on Nurse Participation in Hospital Affairs (survey item numbers 5, 6,
11, 15, 17, 21, 23, 27, 28)


12c) Mean score on Nursing Foundations for Quality of Care (survey item numbers 4,
14, 18, 19, 22, 25, 26, 29, 30, 31)
12d) Mean score on Nurse Manager Ability, Leadership, and Support of Nurses
(survey item numbers 3, 7, 10, 13, 20)
12e) Mean score on Staffing and Resource Adequacy (survey item numbers 1, 8, 9,
12)
12f) Mean score on Collegial Nurse-Physician Relations (survey item numbers 2, 16,
24)
12g) Three category variable indicating favorable, mixed, or unfavorable practice
environments: favorable = four or more subscale means exceed 2.5; mixed =
two or three subscale means exceed 2.5; unfavorable = zero or one subscales
exceed 2.5.

• Registered Nurses with direct patient care responsibilities for 50% or
greater of their job
• Full time, part time, and PRN or per diem RN’s employed by the hospital
• Eligible nurses from all hospital units

Excluded Populations
• New hires of less than 3 months
• Agency, traveler or contract nurses
• Nurses in management, supervisory, or educator roles with direct patient
care responsibilities less than 50% of their job, whose primary
responsibility is administrative in nature

Subscales Required Data Elements:

Nurse Participation in Hospital Affairs
• PES-NWI Career Development
• PES-NWI Participation in Policy Decisions
• PES-NWI Chief Nursing Officer Visibility
• PES-NWI Chief Nursing Officer Authority
• PES-NWI Advancement Opportunities
• PES-NWI Administration Listens and Responds
• PES-NWI Staff Nurses Hospital Governance
• PES-NWI Nursing Committees
• PES-NWI Nursing Administrators Consult

Nursing Foundations for Quality of Care
• PES-NWI Continuing Education
• PES-NWI High Nursing Care Standards
• PES-NWI Philosophy of Nursing
• PES-NWI Nurses Are Competent
• PES-NWI Quality Assurance Program



• PES-NWI Preceptor Program
• PES-NWI Nursing Care Model
• PES-NWI Patient Care Plans
• PES-NWI Continuity of Patient Assignments
• PES-NWI Nursing Diagnosis

Nurse Manager Ability, Leadership, and Support of Nurses
• PES-NWI Supportive Supervisory Staff
• PES-NWI Supervisors Learning Experiences
• PES-NWI Nurse Manager and Leader
• PES-NWI Recognition
• PES-NWI Nurse Manager Backs up Staff

Staffing and Resource Adequacy
• PES-NWI Adequate Support Services
• PES-NWI Time to Discuss Patient Problems
• PES-NWI Enough Nurses for Quality Care
• PES-NWI Enough Staffing

Collegial Nurse-Physician Relations
• PES-NWI Nurse and Physician Relationships
• PES-NWI Nurse and Physician Teamwork
• PES-NWI Collaboration

Composite Score
• Mean of subscale scores

Three Category Variable
• Favorable = four or more subscale means exceed 2.5
• Mixed = two or three subscale means exceed 2.5
• Unfavorable = zero or one subscales exceed 2.5

Data Elements Crosswalk with Survey Questions/Items:
PES-NWI Adequate Support Service Adequate support services allow me to spend time
with my patients (1)
PES-NWI Administration Listens and Administration that listens and responds to
Responds employee concerns (21)
PES-NWI Advancement Opportunities for advancement (17)
Opportunities
PES-NWI Career Development Career development/clinical ladder opportunity (5)

PES-NWI Chief Nursing Officer A chief nurse officer equal in power and authority
Authority to other top-level hospital executives (15)
PES-NWI Chief Nursing Officer A chief nursing officer who is highly visible and
Visibility accessible to staff (11)



PES-NWI Collaboration Collaboration (joint practice) between nurses and
physicians (24)
PES-NWI Continuing Education Active staff development or continuing education
programs for nurses (4)
PES-NWI Continuity of Patient Patient care assignments that foster continuity of
Assignments care, i.e., the same nurse cares for the patient
from one day to the next (30)
PES-NWI Enough Nurses for Quality Enough registered nurses to provide quality
Care patient care (9)
PES-NWI Enough Staffing Enough staff to get the work done (12)
PES-NWI High Nursing Care High standards of nursing care are expected by
Standards the administration (14)
PES-NWI Nurse and Physician Physicians and nurses have good working
Relationships relationships (2)
PES-NWI Nurse and Physician A lot of team work between nurses and physicians
Teamwork (16)
PES-NWI Nurse Manager and A nurse manager who is a good manager and
Leader leader (10)
PES-NWI Nurse Manager Backs up A nurse manager who backs up the nursing staff
Staff in decision making even if the conflict is with a
physician (20)
PES-NWI Nurses Are Competent Working with nurses who are clinically competent
(19)
PES-NWI Nursing Administrators Nursing administrators consult with staff on daily
Consult problems and procedures (28)
PES-NWI Nursing Care Model Nursing care is based on a nursing, rather than a
medical, model (26)
PES-NWI Nursing Committees Staff nurses have the opportunity to serve on
hospital and nursing committees (27)
PES-NWI Nursing Diagnosis Use of nursing diagnosis (31)
PES-NWI Participation in Policy Opportunity for staff nurses to participate in policy
Decisions decisions (6)
PES-NWI Patient Care Plans Written, up-to-date care plans for all patients (29)
PES-NWI Philosophy of Nursing A clear philosophy of nursing that pervades the
patient care environment (18)
PES-NWI Preceptor Program A preceptor program for newly hired RNs (25)
PES-NWI Quality Assurance An active quality assurance program (22)
Program
PES-NWI Recognition Praise and recognition for a job well done (13)
PES-NWI Staff Nurses Hospital Staff nurses are involved in the internal
Governance governance of the hospital (e.g. practice and
policy committees) (23)
PES-NWI Supervisors Learning Supervisors use mistakes as learning
Experiences opportunities, not criticism (7)
PES-NWI Supportive Supervisory A supervisory staff that is supportive of the nurses
Staff (3)


PES-NWI Time to Discuss Patient Enough time and opportunity to discuss patient
Problems care problems with other nurses (8)

Data Elements:
• Number of Responses
• Survey Date
• Survey Distribution Date
• Total Number of Surveys Distributed
• Total Number of Surveys Returned
• Type of Unit

Risk Adjustment: Not Applicable

Data Collection Approach: Concurrent, retrospective

Data Accuracy: None

Measure data can be analyzed by Type of Unit to allow for internal hospital analysis and
quality improvement initiatives. The unit size (number of eligible RNs), number of
responses and the issue of anonymity may be considerations in unit-level analysis. To
protect anonymity, unit-level findings should only be reported for units with 5 or more
respondents. Data elements needed for unit-level analysis include respondent's Unit of
Employment, Number of Surveys Distributed per unit and Number of Surveys Returned
per unit. Additional data elements needed for unit-type analysis include a
comprehensive list of unit types covering the area of employment of all eligible RNs.
The measure is publicly reported at the hospital level.

Hospitals are encouraged to calculate the response rate when conducting analysis of
this measure. The response rate is the proportion of eligible nurses who respond to the
survey. Hospitals may also wish to examine the number of responses for each question
against the total number of submitted surveys. Unit response rates of >50% are
generally considered adequate to support validity of unit-level data.

Sampling: Yes
According to Lake and Friese (2006) the minimum number of completed surveys per
hospital for satisfactory estimates is 15, therefore considering a typical response rate of
60%, a random sample of at least 25 nurses needs to be surveyed annually. For
purposes of public reporting the measure a minimum of 30 completed surveys is
desired, therefore hospitals who choose to sample should sample a minimum of 50
nurses annually. While a random sample may be used at the hospital-level, it is
recommended that hospitals survey all eligible nurses to allow all nurses the opportunity
to complete the practice environment survey instrument.

Data Reported as: Aggregate measure of central tendency



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Lake, Eileen, et al.



Appendix A
Glossary of Terms

Accuracy (of data) The extent to which data are free of identifiable errors.

Administrative/Billing Data (data source) Administrative data are patient-identifiable
data used for administrative, regulatory, and payment (financial) purposes.
Administrative data generally reflects the content of discharge abstracts (for example,
demographic information on patients such as age, sex, zip code; information about the
episode of care such as Point of Origin for Admission or Visit, length of stay, discharge
status; and ICD-9-CM diagnosis and procedure codes). Namely, the Uniform Bill of the
Health Care Financing Administration (UB-04) provides specifications for the abstraction
of administrative/billing data.

Advanced Practice (registered) Nurse (APN/APRN) The role of advanced practice
nurses is determined by state-level boards of nursing through nursing practice acts; the
National Council of State Boards of Nursing (NCSBN) has developed model nursing
practice act language at
www.ncsbn.org/public/regulation/nursing_practice_model_practice_act.htm. Advanced
Practice Nurse (APN, APRN) titles may vary between state and clinical specialities.
Some common titles that represent the advanced practice nurse role are:
o Nurse Practitioner (NP)
o Certified Registered Nurse Anesthetist (CRNA)
o Clinical Nurse Specialist (CNS)
o Certified Nurse Midwife (CNM)

Aggregate (hospital data) Aggregate data elements derived for a specific hospital
from the results of each measures algorithm over a given time period (e.g., monthly,
quarterly). These data are transmitted to The Joint Commission by ORYX® Vendors.

Aggregate (measurement data) Measurement data collected and reported by
organizations as a sum or total over a given period (e.g., monthly, quarterly), or for
certain groupings (e.g., health care organization level)

Aggregate Risk-Adjusted Data Elements Aggregate data elements derived from
episode of care (EOC) records that result from the application of risk adjustment models
by ORYX Vendors for transmission to The Joint Commission.

Algorithm An ordered sequence of data element retrieval and aggregation through
which numerator and denominator events or continuous variable values are identified by
a measure. The algorithms are depicted using flowcharting symbols.

Allowable Value A list of acceptable responses for a data element.

ANSI X12 The American National Standards Institute’s standard for transmitting data
electronically, or electronic data interchange (EDI).

NSC Measure Set Appendix A-1


Assisted Fall A fall in which any staff member (whether nursing service employee or
not) was with the patient and attempted to minimize the impact of the fall by easing the
patient’s descent to the floor or in some manner attempting to break the patient’s fall.
“Assisting” the patient back into bed or chair after a fall is not an assisted fall. A fall that
is reported to have been assisted by a family member or visitor also does not count as
an assisted fall.

Binary Outcome Events or conditions that occur in one or two possible states often
labeled 0 or 1. Such data are frequently encountered in medical research. Common
examples include dead or alive, and improved or not improved.

Caregiver The patient’s family or any other person who will be responsible for care of
the patient after discharge.

Central Line An intravascular catheter that terminates at or close to the heart or in one
of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic
monitoring. The following are considered great vessels for the purposes of reporting
central- line infections and counting central-line days for the CLABSI measure: Aorta,
pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal
jugular veins, and subclavian veins, external iliac veins and common femoral veins.
• NOTE: An introducer is considered an intravascular catheter
• NOTE: In neonates, the umbilical artery/vein is considered a great vessel
• NOTE: Neither [the location of] the insertion site nor the type of device may be
used to determine is a line qualifies as a central line. The device must terminate
in one of these vessels or in or near the heart to qualify as a central line.
• Pacemaker wires and other non-infusion devices inserted into central blood
vessels or the heart are not considered central lines because fluids are not
infused, pushed, nor withdrawn through such devices.
o Umbilical Catheter: A central vascular device inserted through the
umbilical artery or vein in a neonate
o Temporary Central Line: Non-tunneled catheter
o Permanent Central Line: Includes
Tunneled catheters, including certain dialysis catheters
Implanted catheters (including ports)

Central Line-associated Bloodstream Infection (CLABSI) A CLABSI is a primary
bloodstream infection (BSI) in a patient that had a central line within the 48-hour period
before the development of the BSI. If the BSI develops within 48-hours of discharge
from a location, it is associated with the discharging location.
NOTE: There is no minimum period of time that the central line must be in place in order
for the BSI to be considered central line-associated.

Central Tendency A property of the distribution of a variable, usually measured by
statistics such as the mean, median, and mode.



Clinical Measures Measures designed to evaluate the processes or outcomes of care
associated with the delivery of clinical services; allow for intra- and interorganizational
comparisons to be used to continuously improve patient health outcomes; may focus on
the appropriateness of clinical decision making and implementation of these decisions;
must be condition specific, procedure specific, or address important functions of patient
care (e.g., medication use, infection control, patient assessment, etc).

Clinical Survey (data sources) Survey data obtained from clinicians who provide
care.

Community Acquired Pressure Ulcer Any pressure ulcer discovered/documented at
the time of hospitalization. An ulcer observed within the first 24 hours from the time of
inpatient admission should be considered community acquired for this measure set.

Comparison Group The group of health care organizations to which an individual
health care organization is compared. (ORYX Vendors transmit aggregated comparison
group data for non-core measures. The Joint Commission will aggregate health care
organization-level data to create the comparison group for each core measure.)

Confounding Factors Intervening variables that distort the true relationship
between/among the variables of interest. They are related to the outcome of interest,
but extraneous to the study question and are non-randomly distributed among the
groups being compared. They can hide a true correlation or give the appearance of a
correlation when none actually exists.

Continuous Variable An aggregate data measure in which the value of each
measurement can fall anywhere along a continuous scale (e.g., the time [in minutes]
from emergency department arrival to administration of thrombolytic).

Continuous Variable Data Elements Those data elements required to construct the
measure as stated in the section labeled “Continuous Variable Statement.”

Contract/Agency Staff Temporary nursing staff that are not employee by your facility
but are:
• Hired on a contractual basis to fill staffing needs for a designated shift or another
short-term basis
• Registry staff from outside the facility (e.g., not floating staff from within the
facility)
• Traveling nurse staff contracted to the facility for a designated period of time

Critical Access Hospital (CAH) Is a rural public, non-profit or for-profit hospital; a
hospital that was closed within the previous ten years; or is a rural health clinic that was
downsized from a hospital that is located in a state that has established a state plan
with CMS for the Medicare Rural Hospital Flexibility Program. A CAH makes available
24-hour emergency care services 7 days per week and are, by definition, located more
than a 35 mile drive from any other hospital or CAH (in mountainous terrain or in areas



with only secondary roads available, the mileage criterion is 15 miles); or is certified by
the state in the state plan as being a necessary provider of health care services to
residents in the area. They provide no more than 15 beds for acute (hospital-level)
inpatient care and provide an annual average length of stay of 96 hours per patient for
acute care patients. An exception to the 15-bed requirement is made for swing-bed
facilities, which are allowed to have up to 25 inpatient beds that can be used
interchangeably for acute or SNF-level care, provided that not more than 15 beds are
used at any one time for acute care. Hospitals certified by the Secretary of the
Department of Health and Human Services (DHHS) as critical access hospitals are
eligible for cost-based reimbursement from Medicare if they meet a specific set of
federal Conditions of Participation (CoPs).

Data Collection The act or process of capturing raw or primary data from a single or
number of sources. Also called “data gathering.”

Data Collection Effort The availability and accessibility of the required data elements,
the relative effort required, and associated cost of abstracting or collecting the data.

Data Element A discrete piece of data, such as patient birthdate or principal diagnosis.
See also denominator data elements, numerator data elements, and continuous
variable data elements.

Data Entry The process by which data are transcribed or transferred into an electronic
format.

Data Quality The accuracy and completeness of measure data on performance in the
context of the analytic purposes for which they will be used.

Data Sources The primary source document(s) used for data collection (for example,
billing or administrative data, encounter form, enrollment forms, medical record).

Data Transmission The process by which data are electronically sent from one
organization to another. For example, a hospital sending patient-level data to its
selected ORYX Vendor, and the vendor sending measure-level data to The Joint
Commission or patient-level data to the QIO Clinical Warehouse.

Denominator The lower part of a fraction used to calculate a rate, proportion, or ratio.
Also the population for a rate-based measure.

Denominator Data Elements Those data elements required to construct the
denominator.

Denominator Statement A statement that depicts the population evaluated by the
performance measure (e.g., “AMI patients with a history of smoking cigarettes anytime
during the year prior to hospital arrival”).



Discrete Variable See rate-based measure.

Direct Patient Care Responsibilities Patient centered nursing activities by unit-based
staff in the presence of the patient and activities that occur away from the patient that
are patient related:
• Medication administration
• Nursing treatment
• Nursing rounds
• Admission, transfer, discharge activities
• Patient teaching
• Patient communication
• Coordination of patient care
• Documentation time
• Treatment planning

Electronic Data Interchange (EDI) An instance of data being sent electronically
between parties, normally according to predefined industry standards.

Empiric Antibiotic Therapy Antibiotic treatment based on the clinician’s judgment and
the patients signs and symptoms and offered before a diagnosis has been confirmed.

Employee Persons who are employed directly by the facility and are on the payroll for
the purpose of providing nursing care. This would include a hospital’s own internal
“registry” staff.

Employment Status Nursing staff may be either employees or contracted (agency)
staff. Nursing care hours (NCH) includes hours worked by both employees and contract
staff.

Episode of Care (EOC) A patient or case-level record submitted to the database.

Excluded Populations Detailed information describing the populations that should not
be included in the indicator. For example, specific age groups, ICD-9-CM procedure or
diagnostic codes, or certain time periods could be excluded from the general population
drawn upon by the indicator.

Extranet A private network using the Internet protocol to securely share business
information or operations with vendors, customers, and/or other businesses. “The Joint
Commission Connect” is the name given to the Joint Commission’s extranet site.

Fall An unplanned descent to the floor (or extension of the floor, e.g., trash can or other
equipment) with or without injury to the patient.

Format Specifies the character length of a specific data element; the type of
information the data element contains: numeric, decimal number, date, time, or
alphanumeric; and the frequency with which the data element occurs.



General Data Elements Data elements that must be collected by hospitals for each
patient record. These data are patient demographic data, hospital identifiers, and
patient identifiers.

Healthcare-Associated Infection (HAI) A localized or systemic condition resulting
from an adverse reaction to the presence of an infectious agent(s) or its toxin(s). There
must be no evidence that the infection was present or incubating at the time of
admission to the acute care setting.

Health Care Organization (HCO) The business entity which is participating in an
ORYX Vendor (e.g., health care organization level data describes information about the
business entity).

Health Care Organization (HCO) Level Data Aggregation of patient level data to
summarize the performance of an individual hospital on a performance measure. This
data is transmitted to The Joint Commission by the hospital’s ORYX Vendor.

Hospital According to the American Hospital Association, hospitals are licensed
institutions with at least six beds whose primary function is to provide diagnostic and
therapeutic patient services for medical conditions by an organized physician staff, and
have continuous nursing services under the supervision of registered nurses.

Hospital Acquired (Nosocomial) Pneumonia Pneumonia contracted while in the
hospital. Also referred to as nosocomial pneumonia.

Hospital Acquired Pressure Ulcer (Nosocomial) An ulcer observed after the first 24
hours from the time of inpatient admission AND for which there is no documentation in
the record indicating the date of first discovery; should be considered as hospital-
acquired.

Hospitalist A physician whose main practice provides care for hospitalized patients.

ICD-9-CM Codes A two-part classification system in current use for coding patient
medical information used in abstracting systems and for classifying patients into
diagnosis-related groups (DRGs). The first part is a comprehensive list of diseases with
corresponding codes compatible with the World Health Organization’s list of disease
codes. The second part contains procedure codes independent of the disease codes.

Incidence Measure A measure of frequency or change of status over time.

Included Population Detailed information describing the population(s) or event(s) that
the indicator intends to measure.



Indwelling Urinary Catheter A drainage tube that is inserted into the urinary bladder
through the urethra, is left in place, and is connected to a closed collection system; also
called a Foley catheter. Does not include straight in-and-out catheters.

Infection Module A set of evidence-based process measures designed to prevent
postoperative infection in the surgical patient.

Infusion The introduction of a solution through a blood vessel via a catheter lumen.
This may include continuous infusions such as nutritional fluids or medications, or it may
include intermittent infusions as flushes or IV antimicrobial administration, or blood, in
the case of transfusion or hemodialysis.
• Umbilical Catheter; A central vascular device inserted through the umbilical
artery or vein in a neonate.
• Temporary Central Line: Non-tunneled catheter
• Permanent Central Line: Includes
o Tunneled catheters, including certain dialysis catheters
o Implanted catheters (including ports)

Initial Patient Populations Detailed information describing the population(s) that the
indicator intends to measure. Details could include such information as specific age
groups, diagnoses, ICD-9-CM diagnostic and procedure codes, CPT codes, revenue
codes, enrollment periods, insurance and health plan groups, etc.

Inpatient Mortality Any patient death occurring while admitted as an in-patient in the
hospital.

Intensive Care Unit (ICU) A nursing care area that provides intensive observation,
diagnosis, and therapeutic procedures for adults and/or children who are critically ill. An
ICU excludes nursing areas that provide step-down, intermediate care or telemetry only.
Specialty care areas are also excluded. The type of ICU is determined by the kind of
patients cared for in that unit. That is, if 80% of patients are of a certain type (e.g.,
patients with trauma), than that ICU is designated as that type of unit (in this case,
trauma). When a unit houses roughly equal populations of medical and surgical
patients, it is called a medical/surgical unit.

Invalid Data Values for data elements that are required for calculating and/or risk
adjusting a core measure that fall outside of the acceptable range of values defined for
that data element. Refer to the Missing and Invalid Data section for further information.

“The Joint Commission Connect” The name given to the Joint Commission’s
extranet site, a secured online connection to The Joint Commission.

Mean A measure of central tendency for a continuous variable measure. The mean is
the sum of the values divided by the number of observations.



Measure Information Form Tool to provide specific clinical and technical information
on a measure. The information contained includes: performance measure name,
description, rationale, numerator/denominator/continuous variable statements, included
populations, excluded populations, data elements, risk adjustment, sampling, data
accuracy, and selected references.

Measure of Performance See performance measure.

Measure-Specific Data Elements Data elements used by one specific measure or
several measures in one specific measure set, such as the heart failure measures.

Median The value in a group of ranked observations that divides the data into two
equal parts.

Medical Record (Data Source) Data obtained from the records or documentation
maintained on a patient in any health care setting (for example, hospital, home care,
long term care, practitioner office). Includes automated and paper medical record
systems.

Military Time A 24 –hour period from midnight to midnight using a 4-digit number of
which the first two digits indicate the hour and the last two digits indicate the minute.

Missing Data No values present for one or more data elements that are required for
calculating and/or risk adjusting a national hospital inpatient quality measure. Refer to
the Missing and Invalid Data section for further information.

Mode The most frequently occurring response for that data element.

Module A set of measures under a common group/topic area (e.g., infection module).

National Hospital Inpatient Quality Measure A standardized performance measure
that meets the Centers for Medicare & Medicaid Services and Joint Commission
evaluation criteria, has precisely defined specifications, can be uniformly embedded in
extant systems, has standardized data collection protocols to permit uniform
implementation by health care organizations and permit comparisons of health care
organization performance over time through the establishment of a national comparative
data base.

National Hospital Inpatient Quality Measure Set A unique grouping of performance
measures carefully selected to provide, when viewed together, a robust picture of the
care provided in a given area (e.g., cardiovascular care).

Non-Core Measure A performance measure defined by the ORYX Vendor that has
undergone review against Joint Commission established measure criteria and has been
accepted for use in the ORYX initiative.



Neonatal Intensive Care Unit (NICU) A patient care area that provides level III care to
infants who are critically ill. Most NICU infants are under the care of a pediatrician who
is a neonatalogist, and the ratio of infants to nurses in the NICU is low (e.g., 2:1). If the
population of a NICU is a combination of level II and III care patients and their
distribution and placement is such that they cannot readily be separated for purposes
of determining the measure population (NSC 7 and NSC 8 ) you may classify the entire
unit as NICU II/III.

Nosocomial Infection An infection acquired by a patient in a health care organization,
especially a hospital. This infection is not present or incubating before admission to a
hospital.

Numerator The upper portion of a fraction used to calculate a rate, proportion, or ratio.

Numerator Data Elements Those data elements necessary or required to construct
the numerator.

Numerator Statement A statement that depicts the portion of the denominator
population that satisfies the conditions of the performance measure to be an indicator
event. For example, “AMI patients (cigarette smokers) who receive smoking cessation
advice or counseling during the hospital stay”.

Nursing Care Hours (NCH) Actual productive, direct patient care hours worked, not
budgeted or scheduled hours that excludes vacation, sick time, orientation, education or
committee time.

Nursing-Centered Intervention Measures Measures that focus on aspects of nursing
intervention and processes of care provided by nursing personnel. Based on the
organization, nature, and quality of nursing care processes.

Nursing-Sensitive, Nursing-Sensitive Processes and Outcomes Processes and
outcomes (and structural proxies for theses processes and outcomes, e.g., skill mix,
nurse staffing hours) are affected, provided, and/or influenced by nursing personnel, but
nursing is not exclusively responsible for them. Nursing-sensitive measures must be
quantifiably influenced by nursing personnel, but the relationship is not necessarily
causal.

Observed Rate The observed rate is the measure rate that is based on a hospital’s
aggregated data for the reporting period. This is calculated as the number of measure
numerator cases for the reporting period divided by the number of denominator cases.
Observed rates are used to measure hospital performances.

ORYX® Vendor An entity consisting of an automated database(s), that facilitates
performance improvement in health care organizations through the collection and
dissemination of process and/or outcome measures of performance. ORYX Vendors
must be able to generate internal comparisons of organization performance over time,



and external comparisons of performance among participating organizations at
comparable times.

Parenteral Not through the alimentary canal but rather by injection through some other
route, as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal,
intrasternal, intravenous, etc.

Paroxysmal Occurring as sudden or periodic attacks or recurrences of symptoms of a
disease; exacerbation.

Patient Days Conceptually, a patient day is 24 hours, beginning the hour of admission
as measured by daily or period censuses. Facilities should use all data available to
them to represent a complete count of the total number of patients per unit, including
"days" of care provided to short stay patients.

Patient Level Data Collection of data elements that depict the health care services
provided to an individual (patient). Patient level data are aggregated to generate
hospital level data and comparison group data.

Patient Survey (Data Source) Survey data are exclusively obtained from patients
and/or their family members/significant others.

Percentile A value on a scale of 100 that indicates the percentage of a distribution that
is equal to or below it.

Performance Measure A quantitative tool (for example, rate, ratio, index, percentage)
that provides an indication of an organization’s performance in relation to a specified
process or outcome. Refer to the Process Measure and the Outcome Measure in
Appendix E.

Performance Measurement System’s Extranet Track (PET) A secured electronic
information and message center available to the Joint Commission’s ORYX Vendors.
Access to the Internet and a browser are necessary to connect to PET. Access to PET
is available by clicking on the “The Joint Commission Connect” link button on the Joint
Commission’s home page http://www.jointcommission.org.

Physical Restraint Any manual method, physical or mechanical device, material, or
equipment that immobilizes or reduces the ability of a patient to move his or her arms,
legs, body or head freely. CMS Hospital Conditions of Participations: Interpretive
Guidelines available at http://www.cms.hhs.gov accessed February 2009.

Pneumonia Pneumonia is defined as an acute infection of the pulmonary parenchyma
that is associated with at least some symptoms of acute infection, accompanied by
presence of acute infiltrate on chest radiograph or auscultatory findings consistent with
pneumonia (such as altered breath sounds and/or localized rales).



Population In statistics this term is used to describe the finite or infinite collection of
“units” which often refer to people, institutions, events, etc.

Predicted Value The statistically expected response or outcome for a patient after the
risk adjustment model has been applied and the patient’s unique set of risk factors have
been taken into account.

Pressure Ulcer A pressure ulcer is localized injury to the skin and/or underlying tissue
usually over a bony prominence, as a result of pressure, or pressure in combination with
shear. A number of contributing or confounding factors are also associated with
pressure ulcers; the significance of these factors is yet to be elucidated.

Prevalence Measure A method that provides a point-in time “snapshot” of an attribute
or event at one point in time.

Prevalence Study A cross sectional survey or study method that provides a point-in
time “snapshot” of an attribute or event at one point in time.

Primary Bloodstream Infections Primary bloodstream infections are classified
according to the criteria used, either as laboratory-confirmed infection (LCBI) or clinical
sepsis (CSEP). CSEP may be used to report only a primary BSI in neonates (< 30 days
old) and infants (< 1 year old).

Process An interrelated series of events, activities, actions, mechanisms, or steps that
transform inputs into outputs.

Productive Hours Actual direct hours worked, not budgeted or scheduled hours.
Excludes vacation, sick time, orientation, education leave, or committee time.

Proportion Measure A measure which shows the number of occurrences over the
entire group within which the occurrence should take place (e.g., AMI patients who
received aspirin within 24 hours before or after hospital arrival over all AMI patients).

Randomization A technique for selecting or assigning cases such that each case has
an equal probability of being selected or assigned. It is done to stimulate chance
distribution, reduce the effects of confounding factors, and produce unbiased statistical
data.

Range A measure of the spread of a data set. The difference between the smallest and
largest observation.

Rate-Based (Measure) An aggregate data measure in which the value of each
measurement is expressed as a proportion or as a ratio. In a proportion, the numerator
is expressed as a subset of the denominator (for example, AMI patients who received
aspirin within 24 hours before or after hospital arrival over all AMI patients). In a ratio,
the numerator and denominator measure different phenomena (for example, the



number of patients with central lines who develop infections divided by the number of
central line days).

Rate Derived by dividing the numerator (e.g., cases that meet the criterion) by the
denominator (e.g., all cases to which the criterion applies) within a given time frame. In
other words, the numerator is a subset of the denominator.

Rationale An explanation of why an indicator is useful in specifying and assessing the
process or outcome of care measured by the indicator. The rationale may include
supportive evidence such as published literature, unpublished studies, focus group
results, etc.

Ratio A relationship between two counted sets of data, which may have a value of zero
or greater. In a ratio, the numerator is not necessarily a subset of the denominator (e.g.,
pints of blood transfused to number of patients discharged).

Registered Nurse (RN) The role of registered nurses is determined by state-level
boards of nursing through nursing practice acts; the NCSBN has developed model
nursing practice act language at
www.ncsbn.org/public/regulation/nursing_practice_model_practice_act.htm

Reliability The ability of the indicator to accurately and consistently identify the events
it was designed to identify across multiple health care settings.

Repeat Fall More than one fall by the same patient in the same month may be
classified as a repeat fall.

Reporting Hospital Data for Annual Payment Update The Reporting Hospital Quality
Data for Annual Payment Update (RHQDAPU) initiative is intended to empower
consumers with quality of care information to make more informed decisions about their
health care, while encouraging hospitals and clinicians to improve the quality of
inpatient care provided to all patients. The hospital quality of care information gathered
through the RHQDAPU initiative is available to consumers on the Hospital Compare
website.

Reporting Period The defined time period which describes the patient’s
end-of-service.

Risk Adjusted Measures Measures that are risk adjusted using statistical modeling or
stratification methods.

Risk Adjusted Rate A rate that takes into account differences in case mix to allow for
more valid comparisons between groups.



Risk Adjustment A statistical process for reducing, removing, or clarifying the
influences of confounding factors that differ among comparison groups (for example,
logistic regression, stratification).

Risk Adjustment Model The statistical algorithm that specifies the numerical values
and the sequence of calculations used to risk adjust (e.g., reduce or remove the
influence of confounding factors) performance measures.

Risk Factor A factor that produces or influences a result. In statistics, an independent
variable used to identify membership of qualitatively different groups.

Risk Factor Value A specific value assigned to a risk factor for a given episode of care
(EOC) record.

Risk Model The statistical algorithm that specifies the numerical values and the
sequence of calculations used to risk adjust (e.g., reduce or remove the influence of
confounding factors) performance measures.

Sampling Frequency If a hospital chooses to sample, they may sample data on either
a monthly or quarterly basis. Refer to the “Sample Size Requirements” discussion in the
Population and Sampling Specifications section for further information.

Sampling A basic statistical technique or process consisting of drawing a limited
number of measurements from as larger source (population) and then analyzing those
measurements to estimate characteristics of the population from which the
measurements have been drawn.

NSC Sampling Method Describes the process used to select a sample. Possible
approaches to sampling include simple random sampling, cluster sampling, systematic
sampling and judgment sampling.

Sampling Method Describes the process used to select a sample. Sampling
approaches for national hospital inpatient quality measures are simple random
sampling, and systematic sampling. Refer to the “Sampling Approaches” discussion in
the Population and Sampling Specifications section for further information.

Sample Size The number of individuals or particular patients included in a study.
Usually chosen so that the study has a particular statistical power of detecting an effect
of a particular size. Refer to the “Sample Size Requirements” discussion in the
Population and Sampling Specifications for further information.

Score A rating, usually expressed as a number, and based on the degree to which
certain qualities or attributes are present (e.g., Glascow coma, ASA scores).

Severity The degree of biomedical risk; or mortality of medical treatment.



Short Stay Patients Patients who are not classified as in-patients. Variously called
short stay, observation, or same day surgery patients who receive care on in-patient
units for all or part of a day.

Simple Random Sample A process in which a sample of data is selected from the
total population in such a way that every case has the same chance of being selected
and that the sample size is met. Refer to the “Sampling Approaches” discussion in the
Population and Sampling Specifications section for further information.

Sitter A sitter is defined as a person employed or assigned to an individual patient, to
constantly observe the patient’s behavior and protect them from harm such as falling,
wondering, pulling on equipment, etc. As an example, sitter may be employed to protect
a patient from harm as an alternative to restraining the patient. The sitter may be
arranged for by the facility or on behalf of the patient by their family, friends, or
guardian. Sitters are often nursing assistants, whose primary responsibility is constant
observation and protection; however, depending on the skill set of the sitter, they may
also be assigned other patient care duties such as assistance with activities of daily
living.

Standard Deviation A measure of variability that indicates the dispersion, spread, or
variation in a distribution.

Strata See stratified measure.

Stratification A form of risk adjustment which involves classifying data into strata
based on one or more characteristics, variables, or other categories.

Stratification Based Approach for Risk Adjustment The process of dividing or
classifying subgroups known as strata in order to facilitate more valid comparisons. For
example, a measure’s outcome may be divided into type of surgery-specific categories
or strata.

Stratified Measure A performance measure that is classified into a number of strata to
assist in analysis and interpretation. The overall or un-stratified measure evaluates all of
the strata together. The stratified measure or each stratum consists of a subset of the
overall measure. For example, surgical patients who received a prophylactic antibiotic
within one hour prior to surgical incision is reported as all surgical patients with the
appropriate ICD-9-CM Principal Procedure Code, who received the prophylactic
antibiotic within one hour prior to surgical incision; however, the stratified measure(s) for
SCIP-Inf-1 is reported by the specific ICD-9-CM Principal Procedure, such as CABG
(SCIP-Inf-1b) or Other Cardiac Surgery (SCIP-Inf-1c).

Stratum See stratified measure.

Sub-Population A population that is part of a larger population. For example, the
measure set VTE evaluates all patients in the hospital. This measure set is broken into



three distinct sub-populations: No VTE (VTE-1 and VTE-2), Principal VTE (VTE-3, VTE-
4, and VTE-5), and Other VTE Only (VTE-3, VTE-4, VTE-5, and VTE-6).

Surgical Care Improvement Project (SCIP) The Surgical Care Improvement Project
(SCIP) is a national quality partnership of organizations focused on improving surgical
care by significantly reducing surgical complications through performance
measurement. Utilizing ten process measures in three separate modules (infection,
cardiac, and VTE), the goal is to reduce the incidence of surgical complications
nationally by 25 percent by the year 2010.

Surgical Infection Prevention (SIP) In August of 2002, the Centers for Medicare &
Medicaid Services and the Centers for Disease Control and Prevention collaborated to
develop the Surgical Infection Prevention project. The Medicare Surgical Infection
Prevention Project was started with the single objective - to decrease morbidity and
mortality associated with postoperative infection in the Medicare patient population. As
of July 2006 discharges, the three SIP measures become the first three SCIP infection
measures.

Systematic Random Sampling A process in which the starting case is selected
randomly, and the next cases are selected according to a fixed interval that is based
upon the number of cases in the population. For example, the starting case is the
second patient that arrives at the hospital. This patient and every subsequent fifth
patient becomes part of the random sample until the sample size is reached. Refer to
the “Sampling Approaches” discussion in the Population and Sampling Specifications
section for further information.

System-Centered Measures Measures that are focused on system-level
organizational effectiveness and efficiency that influences and is influenced by
healthcare, including the provision of care by nursing staff and their performance. Based
on the structural, organizational, work process, and work design-related elements of the
work environment.

Transmission Schedule The schedule of dates on which data are expected to be
transmitted to The Joint Commission and the QIO Clinical Warehouse.

Umbilical Catheter A central vascular infusion device inserted through the umbilical
artery/vein.

Unable to Determine (UTD) Each data element that is applicable per the algorithm for
each of the measures within a topic must be “touched” by the abstractor. While there is
an expectation that all data elements are collected, it is recognized that in certain
situations information may not be available (i.e., dates, times, codes, etc.). If, after due
diligence, the abstractor determines that a value is not documented or is not able to
determine the answer value, the abstractor must select “Unable to Determine (UTD)” as
the answer.



Unit ID /Numeric Code An assigned unique unit ID number.

Unlicensed Assistive Personnel (UAP) Individuals trained to function in an assistive
role to nurses in the provision of patient care, as delegated by and under the
supervision of the registered nurse. Typical activities performed by UAPs may include
(but are not limited to): Taking vital signs; Bathing, feeding, or dressing patients;
Assisting patient with transfers, ambulation, or toileting. In some states assistive
personnel are licensed.

Validation The process by which the integrity and correctness of data are established.
Validation processes can occur immediately after a data item is collected or after a
complete set of data are collected. The Centers for Medicare & Medicaid Services
(CMS) chart level validation will validate the data at several levels. There are
consistency and internal edit checks to assure the integrity of the submitted data; there
are external edit checks to verify expectations about the volume of the data received,
and there will be chart level audits to assure the reliability of the submitted data.
Information on these procedures is available on http://www.qualitynet.org.

Validity Ability to identify opportunities for improvement in the quality of care;
demonstration that the indicator use results in improvements in outcomes and/or quality
of care.

Variance Equal to the square of the standard deviation.

Venous Thromboembolism (VTE) A term that includes deep vein thrombosis and/or
pulmonary embolism.

Ventilator A device to assist or control respiration continuously, inclusive of the
weaning period, through a tracheostomy or by endotracheal intubation.
Note: Lung expansion devices such as intermittent positive pressure breathing (IPPB);
nasal positive end-expiratory pressure (PEEP); continuous nasal positive airway
pressure (CPAP, hypoCPAP) are not considered ventilators unless delivered via
tracheostomy or endotracheal intubation (e.g., ET-CPAP).

Verification The process used to ensure consistent implementation of core measure
algorithms specified in this manual across disparate ORYX Vendors.

Voluntary Turnover Voluntary turnover or voluntary uncontrolled separation is defined
within the context of this performance measure set as separations that are primarily due
to employee dissatisfaction with their job (including aspects such as compensation,
work environment, team members, or management); excluding other recognized causes
of separation such as relocation, retirement or termination.



Selected Sources:

Babbie, ER, The Practice of Social Research, 2nd edition, Belmont, CA: Wadsworth
Publishing Company, 1979.

Disease-Specific Care Certification Manual, 2nd Edition. Joint Commission on
Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. 2005.

Everitt, BS, The Cambridge Dictionary of Statistics, Cambridge University Press, 1998.

Iezonni, LI, Foley, SM, Heeran, T, Daley, J, Duncan, CC, Fisher, ES, Hughes, J, “A
Method for Screening the Quality of Hospital Care Using Administrative Data:
Preliminary Validation Results,” Quality Review Bulletin, November, 1992, 361- 370.

Lexikon Second Edition, Oakbrook Terrace, IL: Joint Commission on Accreditation of
Healthcare Organizations, 1998.

McHorney, CA, Kosinski, M, and Ware, Jr., JE, “Comparisons of the Cost and Quality of
Norms for the SF-36 Health Survey Collected by Mail Versus Telephone Interview:
Results From a National Survey,” Medical Care, 32, (1994), 551-567.

Mosby’s Dictionary of Medicine, Nursing & Health Professions, 7th Edition. Mosby
Elsevier, St. Louis, MO. 2006.

Nichols, T and Earl, L, Basic ICD-9-CM Coding Handbook, Chicago, IL: American
Health Information Management Association, 1992.

ORYX® Technical Implementation Guide, The Joint Commission, Oakbrook Terrace,
Illinois, current.

2008 Comprehensive Accreditation Manual for Hospitals; The Joint Commission,
Oakbrook Terrace, Illinois, 2007.

Taber’s Cyclopedic Medical Dictionary. F.A. Davis Company, Philadelphia, PA. 1997.

NSC Selected Sources

Codebook Part II Acute Care Version January 1, 2005 Revision, California Nursing
Outcomes; Coalition Project

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel.
Prevention and treatment of pressure ulcers: quick reference guide. Washington DC:
National Pressure Ulcer Advisory Panel; 2009.



Guidelines for Data Collection and Submission on Quarterly Indicators, Version 5.0, The
American Nurses Association

Hospital Epidemiology and Infection Control, 3rd ed. CG Mayhill, editor. Philadelphia:
Lippincott Williams & Wilkins, 2004.

National Healthcare Safety Network (NHSN) Manual: Patient Safety Component
Diseases, Centers for Disease Control and Prevention. U.S. Department of Health and
Human Services. Atlanta, Georgia 30333. Available at http://www.cdc.gov/nhsn/.

National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial
Performance Measure Set, A Consensus Report. National quality Forum (NQF),
Washington DC:NQF;2004

Specifications Manual for National Hospital Quality Measures, 2009, CMS & Joint
Commission.

VHA Inc.



Appendix B
Overview of Measure Information Form and Flowchart Formats

Measure Information Form Introduction

Measure Set
The specific national hospital quality measure set, to which an individual measure
belongs (for example, acute myocardial infarction, pneumonia).

Set Measure ID #
A unique alpha-numeric identifier assigned to a measure. Information associated with a
measure is identified by this unique alpha-numeric number.

Performance Measure Name
A brief title that uniquely identifies the measure.

Description
A brief explanation of the measure’s focus, such as the activity or the area on which the
measure centers attention (for example, pain management for terminally ill patients)

Rationale
An explanation that states why it is important to receive data/information on this
measure. This may include specific literature references, evidence based information,
expert consensus, etc.

Type of Measure
Indicates whether the measure is used to examine a process or an outcome over time.
• Process: A measure used to assess a goal directed, interrelated series of
actions, events, mechanisms, or steps, such as measure of performance that
describes what is done to, for, or by patients, as in performance of a procedure.

• Outcome: A measure that indicates the result of performance (or non-
performance) of a function(s) or process(es).

Improvement Noted As
Describes how improvement would be indicated by the measure.
• An increase in the rate/score/number of occurrences (for example,
immunizations)
• A decrease in the rate/score/number of occurrences (for example, surgical site
infections)
• Either an increase or a decrease in the rate/score/number of occurrences,
depending upon the context of the measure (for example, utilization)

Numerator Statement
Represents the population/events that satisfy the conditions of the performance
measure to be an indicator event.

NSC Measure Set Appendix B-1


NOTE: If the measure is reported as a rate (proportion or ratio), the Numerator and
Denominator Statement are completed. If a performance measure does not have both
a numerator and a denominator, then a Continuous Variable Statement is completed.

Included Population in Numerator
Specific information describing the population/event(s) comprising the numerator, not
contained in the numerator statement, or not applicable. Population inclusion
information described in the denominator statement is not repeated.

Excluded Population in Numerator
Specific information describing the population/event(s) that should not be included in the
numerator, or none. Population exclusion information described in the denominator
statement is not repeated.

Data Elements
Those data elements necessary or required to construct the numerator.

Denominator Statement
Represents the population/count data evaluated by the performance measure.
NOTE: If measure is reported as a rate (proportion or ratio), the Numerator and
Denominator Statement are completed. If a performance measure does not have both
a numerator and a denominator, then a Continuous Variable Statement is completed.

Included Population in Denominator
Specific information describing the population/count data comprising the denominator,
not contained in the denominator statement or not applicable

Excluded Population in Denominator
Specific information describing the population/count data that should not be included in
the denominator, or none

Data Elements
Those data elements required to construct the denominator.

Continuous Variable Statement
Describes an aggregate data measure in which the value of each measurement can fall
anywhere along a continuous scale.
NOTE: If measure is reported as a central tendency, Continuous Variable Statement is
completed. This item is only completed when the performance measure does not have
numerator and denominator statements.

Included Population in Continuous Variable
Specific information describing the population(s) comprising the performance measure,
not contained in the continuous variable statement or not applicable

Excluded Population in Continuous Variable
Specific information describing the population(s) that should not be included in the
performance measure or none



Date Elements
Those data elements required to construct the measure for a continuous variable.

Risk Adjustment
Indicates whether a measure is subject to the statistical process for reducing, removing,
or clarifying the influences of confounding factors to allow more useful comparisons.

Data Collection Approach
Recommended timing for when data should be collected for a measure. Data collection
approaches include retrospective, concurrent or prospective data collection.
Retrospective data collection involves collecting data for events that have already
occurred. Concurrent data collection is the process of gathering data on how a process
works or is working while a patient is in active treatment. Prospective data collection is
data collection in anticipation of an event or occurrence.

Data Accuracy
Recommendations to reduce identifiable data errors, to the extent possible.

Measure Analysis Suggestions
Recommendations to assist in the process of interpreting data and drawing valid
conclusions.

Terminology
Definitions for terms used within the measure.

Sampling
Indicates whether a measure is amenable to selecting a random subset of a population
in order to estimate the organization’s performance level without collecting data for the
entire population.

Data Reported As
Indicates how data will be reported for a measure.
• Aggregate rate generated from count data reported as a proportion (for
example, rate-based measures which report summary data generated from the
number of Cesarean sections as a proportion of deliveries)
• Aggregate rate generated from count data reported as a ratio (for example,
bloodstream infection per 1,000 line days)
• Aggregate measures of central tendency (for example, continuous variables
which report means and medians such as length of stay).

Selected References
Specific literature references that are used to support the importance of the
performance measure.



Appendix C

Resources

The following are available resources to those using the Nursing-Sensitive Care
Implementation Guide.

ORYX® Vendors
If you are an ORYX Vendor with questions about Implementation Guide, please contact
The Joint Commission’s Division of Quality Measurement and Research at
http://manual.jointcommission.org/.

Abstraction or Measure Questions
The Joint Commission, please submit to http://manual.jointcommission.org/.

Agency for Healthcare Research and Quality (AHRQ)
http://www.ahrq.gov/
Patient Safety Indicator (PSI) Technical Specifications Version 4.0 (June 2009):

For questions regarding the technical specifications for the Agency for Healthcare
Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs) and Inpatient Quality
Indicators (IQIs), contact: support@qualityindicators.ahrq.gov Or: (888) 512–6090

For questions regarding CMS’ calculations of the PSIs and IQIs for the RHQDAPU
program, contact: AHRQmeasuresforRHQDAPU@mathematica-mpr.com

Centers for Disease Control and Prevention
http://www.cdc.gov/
National Healthcare Safety Network (NHSN) Patient Safety Component Protocol

National Uniform Billing Committee (NUBC)
For further information regarding the UB-04 and NUBC related data elements, please
refer to the NUBC manual, “Official UB-04 Data Specifications Manual Copyright©
American Hospital Association” or website at http://www.nubc.org/index.html.

NSC Measure Set


Appendix D:
Miscellaneous Tables

TABLE 1. International NPUAP-EPUAP Pressure Ulcer Guidelines

Used in measure NSC-2 Pressure Ulcer Prevalence

International NPUAP-EPUAP Pressure Ulcer Definition
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in combination with shear. A
number of contributing or confounding factors are also associated with pressure ulcers;
the significance of these factors is yet to be elucidated.

NPUAP / EPUAP Pressure Ulcer Classification System

Category/Stage I: Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony
prominence. Darkly pigmented skin may not have visible blanching; its color may differ
from the surrounding area. The area may be painful, firm, soft, warmer or cooler as
compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals
with dark skin tones. May indicate “at risk” persons.

Category/Stage II: Partial thickness
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink
wound bed, without slough. May also present as an intact or open/ruptured serum-filled
or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough
or bruising*. This category/stage should not be used to describe skin tears, tape burns,
incontinence associated dermatitis, maceration or excoriation.
*Bruising indicates deep tissue injury.

Category/Stage III: Full thickness skin loss
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle
are not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling. The depth of a Category/Stage III pressure
ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus
do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be
shallow. In contrast, areas of significant Quick Reference Guide Prevention 8 adiposity
can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not
visible or directly palpable.

Category/Stage IV: Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may
be present. Often includes undermining and tunneling. The depth of a Category/Stage
IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and
malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow.

NSC Measure Set Appendix D-1


Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g.,
fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed
bone/muscle is visible or directly palpable.

Additional Categories for the USA
Unstageable/ Unclassified: Full thickness skin or tissue loss – depth unknown
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by
slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the
wound bed. Until enough slough and/or eschar are removed to expose the base of the
wound, the true depth cannot be determined; but it will be either a Category/Stage III or
IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels
serves as “the body’s natural (biological) cover” and should not be removed.

Suspected Deep Tissue Injury – depth unknown
Purple or maroon localized area of discolored intact skin or blood-filled blister due to
damage of underlying soft tissue from pressure and/or shear. The area may be
preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to
adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin
tones. Evolution may include a thin blister over a dark wound bed. The wound may
further evolve and become covered by thin eschar. Evolution may be rapid exposing
additional layers of tissue even with optimal treatment.

Source:
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel.
Prevention and treatment of pressure ulcers: quick reference guide. Washington DC:
National Pressure Ulcer Advisory Panel; 2009.



TABLE 2. Patient Day Reporting Methods Table

Used in measures NSC-4 Patient Falls, NSC-5 Falls with Injury, and NSC-10 Nursing
Care Hours Per Patient Day

Method Definition
Method 1 Midnight Census This is accurate for units that have all in-
patient admission. It is the least accurate
methods for units that have both in-patient
and short stay patients. The daily number
should be summed for every day in the
month.
Method 2 Midnight Census + Patient This is an accurate method for units that
Days from Actual Hours for Short Stay have both in-patients and short stay
Patients patients. The short stay “days” should be
reported separately from midnight census
and summed to obtain patient days. The
total daily hours for short stay patients
should be summed for the month and
divided by 24.
Method 3 Patient Days from Actual This is the most accurate method. An
Hours increasing number of facilities have
accounting systems that track the actual
time spent in the facility by each patient.
Sum the actual hours for all patients,
whether in-patient or short stay, and divide
by 24.
Method 4 Patient Days Averaged from Some facilities collect census multiple times
Multiple Census Reports per day (e.g., every 4 hours or each shift).
This method is more accurate than the
Midnight Census, but not as accurate as
Midnight Census + Actual Short Stay Hours
or as Actual Patient Hours. A sum of the
daily average censuses can be calculated
to determine patient days for the month on
the unit.

Note: For all patient day reporting methods, it is recommended that hospitals
consistently use the same method for a reporting unit over time. However, units with
short stay patients should transition either to Method 2 or Method 3 when it becomes
feasible.

Source:
(NDNQI)



TABLE 3. Unit Structure Definitions

Used in measures NSC-2 Pressure Ulcer Prevalence, NSC-3 Restraint Prevalence,
NSC-4 Patient Falls, NSC-5 Falls with Injury, NSC-9 Skill Mix, NSC-10 Nursing Care
Hours Per Patient Day, NSC-11 Voluntary Turnover, and NSC-12 PES-NWI

Unit Type Definition
Name
Critical 90% or greater of the patients served on this unit require the highest level
Care-adult of care, includes all types of intensive care units. Specialty designations
may include: Burn, Cardiothoracic, Coronary Care, Medical, Neurology,
Pulmonary, Surgical and Trauma ICU.
Step-Down- 90% or greater of the patients served on this unit require a lower level of
adult care than critical care units and higher level of care than provided on
medical-surgical units. Examples include progressive care or intermediate
care units. Telemetry is not an indicator of acuity level. Specialty
designations may include: Med-Surg, Medical or Surgical Step-Down
units.
Medical- 90% or greater of the patients served on this unit are admitted to medical
adult services, such as internal medicine, family practice, or cardiology.
Specialty designations may include: Bone M arrow Transplant, Cardiac,
Gastro-intestinal, Infectious Disease, Neurology, Oncology, Renal or
Respiratory Medical units.
Surgical- 90% or greater of the patients served on this unit are admitted to surgical
adult services, such as general surgery, neurosurgery, or orthopedics. Specialty
designations may include: Bariatric, Cardiothoracic, Gynecology,
Neurosurgery, Orthopedic, Plastic Surgery, Transplant or Trauma Surgical
unit.
Med-Surg Patients served on this unit are patients admitted to either medical or
Combined- surgical services with less than 90% of one type. Specialty designations
adult include: Cardiac, Neuro/Neurosurgery or Oncology med-surg combined
units.
Mixed Patients served on this unit are patients with less than 90% of one level of
Acuity-adult acuity such as combined ICU and step-down beds, or step-down beds on
a med-surg floor or universal bed units.

Note:
To select the unit types first determine the acuity level of the patients typically served on
the unit. If the unit has 90% or greater of the same acuity type, select that acuity level.
If the unit acuity level does not meet the criteria of 90% or greater for one acuity level
type, then select mixed acuity unit. For example, if 90% or greater of the patients
typically served on the unit require the highest level of care select critical care unit; if the
unit has 30% step-down or intermediate level of care and 70% med-surg patients select



mixed acuity unit; if the level of acuity is med/surg, and the unit typically serves 90% or
greater surgical patients select surgical unit type; if the unit acuity level is med/surg and
serves 60% medical and 40% surgical, select med-surg combined unit.
To select a specialty unit or location type the patients served must be 80% or greater of
the same specialty type to select the specialty or location type. For example if 80% of
the patients served are cardiac surgery select surgical cardiothoracic critical care. For
NSC 6, 7, and 8 when selecting the Location or Location of Attribution data element and
the unit does not meet the criteria of 80% of one specialty type, the location should be
mapped to the CDC Location equivalent specialty type.

Source:
(NDNQI)



TABLE 4. ICU Location Definitions

Used in measures NSC-6 CAUTI, NSC-7 CLABSI, and NSC-8 VAP

LOCATION CODE
Burn-Critical Care - Adult B-Adult
Medical Cardiac Critical Care MC-Adult
Surgical Cardiothoracic Critical Care SCT-Adult
Medical Critical Care M-Adult
Combined medical-surgical Critical Care-Adult MS1-Adult
major teaching hospital
Combined medical-surgical Critical Care-Adult MS0
(hospitals other than major teaching)
Neurologic Critical Care-Adult N-Adult
Neurosurgical Critical Care-Adult NS-Adult
Respiratory Critical Care-
Adult R-Adult
Surgical Critical Care-Adult S-Adult
Trauma Critical Care-Adult T-Adult
Burn Critical Care-Pediatric B-Ped
Cardiothoracic Critical Care-Pediatric CT-Ped
Medical Critical Care-
Pediatric M-Ped
Medical-Surgical Critical Care MS-Ped
Neurosurgical Critical Care-Pediatric NS-Ped
Respiratory Critical Care-Pediatric R-Ped
Surgical Critical Care-
Pediatric S-Ped
Trauma Critical Care-
Pediatric T-Ped

Note:
To select the unit types first determine the acuity level of the patients typically served on
the unit. If the unit has 90% or greater of the same acuity type, select that acuity level.
If the unit acuity level does not meet the criteria of 90% or greater for one acuity level
type, then select mixed acuity unit. For example, if 90% or greater of the patients
typically served on the unit require the highest level of care select critical care unit; if the
unit has 30% step-down or intermediate level of care and 70% med-surg patients select
mixed acuity unit; if the level of acuity is med/surg, and the unit typically serves 90% or
greater surgical patients select surgical unit type; if the unit acuity level is med/surg and
serves 60% medical and 40% surgical, select med-surg combined unit.



To select a specialty unit or location type the patients served must be 80% or greater of
the same specialty type to select the specialty or location type. For example if 80% of
the patients served are cardiac surgery select surgical cardiothoracic critical care. For
NSC 6, 7, and 8 when selecting the Location or Location of Attribution data element and
the unit does not meet the criteria of 80% of one specialty type, the location should be
mapped to the CDC Location equivalent specialty type.

Source:



TABLE 5. Calculation of Monthly Nursing Care Hours

Used in measures NSC-9 Skill Mix and NSC-10 Nursing Care Hours Per Patient Day

Suppose a bi-weekly pay period begin on Saturday 29th of the previous month. There
are 11 days of this pay period in the current month. So multiply Nursing care hours in
this pay period by .
The next pay period is completely contained in the month.
The last pay period has 5 days in the current month. So multiply payroll hours in this
pay period by .

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

23 24 25 26 27 28 29

30 31 1 2 3 4 5
Pay Period 1

6 7 8 9 10 11 12

13 14 15 16 17 18 19
Pay Period 2

20 21 22 23 24 25 26

27 28 29 30 1 2 3
Pay Period 3

4 5 6 7 8 9 10



Example:
Nursing Number of
Care Days in Current
Hours Month
Pay Period 1 560 11 440
Pay Period 2 630 14 630
Pay Period 3 588 5 210
Total in this Month 30 1280

There are 1280 Nursing care hours for this month.

Source:
(NDNQI)



Appendix E
Prevalence Study Methodology

General Information
The time and staff required to do a prevalence study depends on the size of the hospital
and the units as well as the study team’s experience in conducting the observation,
extracting required data elements from the clinical record and documenting the
information. Experienced sites have indicated that the prevalence study process
requires some learning at first and benefits from a core group of staff that is very skilled
in the study area. This greatly improves the validity and reliability of the data. Other
suggestions include the pairing of less experienced staff with experts, in teams, to
provide a rich teaching/learning experience and as a valuable competency development
strategy. It is also important that the study team(s) has (have) at least one
planning/training session prior to the day on which the study is conducted.

For those organizations that are members of a multi-hospital system, it may be
beneficial to consider the development of an expert team to travel between hospitals. In
this way, the expertise and efficiency of the prevalence study is maximized. Another
suggestion is to have sites mentor one another – so if this is your organization’s first
prevalence study, consider observing, first hand, another site conduct their prevalence
study. The insight and experience gained can then be applied as your organization
plans and conducts its own first study. Finally, some hospitals have found it convenient
to conduct the pressure ulcer and restraint prevalence studies at the same time.

Prevalence Study Procedures

1) Assign a coordinator
A coordinator should be selected who has organizational, problem-solving and
leadership skills. Responsibilities of the coordinator include communications,
selecting the study date, finalizing the data collection tool, training the data
collectors, managing questions/concerns, and assuring the data are collated. The
coordinator should ensure that all observers are trained in the study methodology
and observation techniques. The coordinator should also monitor Inter-rater (inter-
observer) reliability as an important component of data quality assessment.

2) Determine Who Will Conduct the Study
a. Pressure Ulcer Prevalence: A combination of exempt nurses with current clinical
skills (e.g., ET nurses, clinical nurse specialists, educators, and unit managers)
and staff nurse experts should be considered for the inspection team. Chart
review may be conducted concurrently by other staff with skill in reading
documentation. Using a “team” for the observation portion of the study may be
helpful for conducting skin inspection (e.g., to help turn immobile patients for
inspection). To help decrease the likelihood of bias in observation, consider
assigning observation team members to study units other than their regularly
assigned work unit. Resources required will vary based on the efficiency of the
teams and the amount of data desired by the facility.

NSC Measure Set Appendix E-1


b. Restraint Use Prevalence: To help decrease the likelihood of bias in
observation, consider assigning observation team members to study units other
than their regularly assigned work unit. Resources required will vary based on
the efficiency of the teams and the amount of data desired by the facility.

3) Train Those Who Will Conduct the Study
a. Pressure Ulcer Prevalence: Training in skin inspection and pressure ulcer
staging/categorization is required prior to study participation. One option would
be to have an ET nurse or clinical expert organize a training session on the
EPUAP/NPUAP Pressure Ulcer Guidelines.
b. Restraint Use Prevalence: Not applicable.

4) Observation
a. Pressure Ulcer Prevalence: Inspect all bony prominences including the traditional
areas such as the coccyx but also areas such as heels, elbows, ears, and
posterior cranium on bedridden patients. If using teams, be sure one person is a
skin expert. Any pressure ulcers found are staged/categorized and recorded on
the data collection tool. Facilities may opt to also measure/photograph ulcers for
their quality programs.
b. Restraint Use Prevalence: Each patient on the assigned unit is observed (i.e.,
observations are not to be referred by staff for those patients thought to be
restrained).

5) Chart Review
a. Pressure Ulcer Prevalence: Each patient’s chart is also reviewed for
demographic data, documentation relative to risk assessment and, if the Braden
Scale is used, Total and Subscale Scores on admission for all patients with
stage/category I or greater ulcers. Sites may also decide to inspect
documentation related to skin care or other standards. Various other quality
management studies may be combined with the prevalence study and data
specific to those may also be included in the chart review.
b. Restraint Use Prevalence: Each patient’s chart is also reviewed for
documentation relative to the clinical justification for use of a restraint or sitter.
Additional information such as other interventions, patient’s condition and length
of time in restraints may be useful to collect for additional analysis.

6) Data Collection Tools
a. Pressure Ulcer Prevalence: Data should be recorded (whether or not pressure
ulcers were noted) for each patient whose skin is observed during the prevalence
study. These data include both the patient observation findings and the chart
review findings. If different team members are doing the observing and chart
review, it is helpful to have the data collection tool divided into distinct portions
(each with a patient identifier) and two systems for tracking which patients have
been completed (observers and chart reviewers proceed at different paces).
b. Restraint Use Prevalence: Data should be recorded (whether or not restraints
were noted) for each patient. These data include both the observation findings



and chart review findings. If different team members are doing the observing and
chart review, it is helpful to have the data collection tool divided into distinct
portions (each with a patient identifier) and two systems for tracking which
patients have been completed (observers and chart reviewers proceed at
different paces).

7) Data Submission
a. Pressure Ulcer Prevalence: After the chart review and patient observation have
been completed, data collection tools should be checked for accuracy, and
completeness. Completed study data should be submitted using a defined
procedure for internal analysis or following procedures as defined for external
data submission.
b. Restraint Use Prevalence: After the chart review and patient observation have
been completed, data collection tools should be checked for accuracy, and
completeness. Completed study data should be submitted using a defined
procedure developed for internal analysis or following procedures as defined for
external data submission.

8) Important Notes
a. Definition: A pressure ulcer is localized injury to the skin and/or underlying
tissue usually over a bony prominence, as a result of pressure, or pressure in
combination with shear and/or friction. (National Pressure Ulcer Advisory Panel,
NPUAP, 2009)
b. Hospital-acquired pressure ulcers are ulcers discovered or documented after
the first 24 hours from the time of inpatient admission.
c. Skin breakdown due to arterial occlusion, venous insufficiency, diabetes related
neuropathy or incontinence dermatitis are not pressure ulcers and should not be
reported in the prevalence study.
d. Healing/Closed or Healed Pressure Ulcers: Pressure ulcers that are healing
should not be reverse staged; rather they should be staged based on the
maximum anatomic depth of tissue damage that was recorded in the patient’s
record. Pressure ulcers that have closed/healed are not counted as pressure
ulcers.
e. Patient consent NOT required: A prevalence study is NOT a research study for
which you must obtain patient consent. It is a Quality Improvement activity like
many others in your facility. The examination is the same as the mandatory skin
examinations your nurses perform on a regular basis. Thus all your nurses need
to do is let patients know that you are examining all patients as part of your
quality procedures. Of course, if they absolutely refuse, you do exclude them.
f. Actively dying and medically unstable patients: The terms “actively dying”
and “medically unstable” are terms used to characterize patients who cannot
safely be turned for physiological reasons. Active dying is considered the last few
days of life when blood flow to organs (e.g., brain, heart, kidneys) is decreasing,
respiratory distress is increasing, and physiological instability is apparent, making
turning unrealistic. “Medically unstable” people may have poor hemodynamic
profiles or distress so severe that they cannot safely be turned for examination of



the back, sacrum scapula, ischea, back of head, etc. The nature of the instability
will vary e.g., some will require upright position to breathe, others cannot tolerate
movement because of changes in hemodynamics (reduction) or intracranial
pressure (increase).
g. A patient with a very long length of stay, who was surveyed previously, should be
counted and surveyed again as long as they remain a patient in your facility.
h. Mucous membrane ulcers are tissue disruption on mucous membranes due to
ischemic pressure from medical devices. Mucous membranes do not have skin
on them so the staging system for pressure ulcers cannot be used to stage
mucosal pressure ulcers. Do NOT report mucous membrane ulcers.

Source:



Appendix F
Device Related Infection Measure Criteria

Urinary Tract Infection Criteria

Criterion Symptomatic Urinary Tract Infection (SUTI) Must meet at least 1 of the
following criteria:
1a Patient had an indwelling urinary catheter in place at the time of specimen
collection
and at least 1 of the following signs or symptoms with no other recognized
cause:
fever (>38° suprapubic tenderness, or costovertebral angle pain or
C),
tenderness
and
a positive urine culture of ≥ 105 colony-forming units (CFU)/ml with no more
than 2 species of microorganisms.
-------------------------------------------------OR------------------------------------------------
Patient had indwelling urinary catheter removed within the 48 hours prior to
specimen collection
and
at least 1 of the following signs or symptoms with no other recognized cause:
fever (>38° urgency, frequency, dysuria, suprapubic tenderness, or
C),
costovertebral angle pain or tenderness
and
a positive urine culture of ≥ 105 colony-forming units (CFU)/ml with no more
than 2 species of microorganisms.
1b Patient did not have an indwelling urinary catheter in place at the time of
specimen collection nor within 48 hours prior to specimen collection
and
has at least 1 of the following signs or symptoms with no other recognized
cause: fever (>38° in a patient that is ≤ 65 years of age, urgency,
C)
frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or
tenderness
and
a positive urine culture of ≥ 105 CFU/ml with no more than 2 species of
microorganisms.
2a Patient had an indwelling urinary catheter in place at the time of specimen
collection
and
fever (>38° suprapubic tenderness, or costovertebral angle pain or
C),
tenderness
and
a positive urinalysis demonstrated by at least 1 of the following findings:
a. positive dipstick for leukocyte esterase and/or nitrite
b. pyuria (urine specimen with ≥ 10 white blood cells [WBC]/mm3 or ≥ 3

NSC Measure Set Appendix F-1


WBC/high power field of unspun urine)
c. microorganisms seen on Gram stain of unspun urine
and
a positive urine culture of ≥ 103 and <105 CFU/ml with no more than 2
species of microorganisms.
------------------------------------------------OR-------------------------------------------------
Patient had indwelling urinary catheter removed within the 48 hours prior to
specimen collection
and
fever (>38° urgency, frequency, dysuria, suprapubic tenderness, or
C),
costovertebral angle pain or tenderness
and
b. pyuria (urine specimen with ≥ 10 white blood cells [WBC]/mm3 or ≥ 3
WBC/high power field of unspun urine)
c. microorganisms seen on Gram stain of unspun urine and a positive
urine culture of ≥ 103 and <105 CFU/ml with no more than 2 species
of microorganisms.
2b Patient did not have an indwelling urinary catheter in place at the time of
specimen collection nor within 48 hours prior to specimen collection
and
has at least 1 of the following signs or symptoms with no other recognized
cause:
fever (>38° in a patient that is ≤ 65 years of age, urgency, frequency,
C)
dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness
and
b. pyuria (urine specimen with ≥ 10 WBC/mm3 or ≥ 3 WBC/high power
field of unspun urine)
c. microorganisms seen on Gram stain of unspun urine
and
a positive urine culture of ≥ 103 and <105 CFU/ml with no more than 2
species of microorganisms.
3 Patient ≤ 1 year of age with or without an indwelling urinary catheter has at
least 1 of the following signs or symptoms with no other recognized cause:
fever (>38° core), hypothermia (<36° core), apnea, bradycardia, dysuria,
C C
lethargy, or vomiting
and
a positive urine culture of ≥ 105 CFU/ml with no more than 2 species of
microorganisms.



4 Patient ≤ 1 year of age with or without an indwelling urinary catheter has at
least 1 of the following signs or symptoms with no other recognized cause:
C C
lethargy, or vomiting
and
a positive urinalysis demonstrated by at least one of the following findings:
b. pyuria (urine specimen with ≥ 10 WBC/mm3 or ≥ 3 WBC/high power field
of unspun urine)
c. microorganisms seen on Gram’s stain of unspun urine
and
a positive urine culture of between ≥ 103 and <105 CFU/ml with no more than
two species of microorganisms.
Criterion Asymptomatic Bacteremic Urinary Tract Infection (ABUTI)
Patient with or without an indwelling urinary catheter has no signs or
symptoms (i.e., no fever (>38° for patients ≤ 65 years of age*; and for any
C)
age patient no urgency, frequency, dysuria, suprapubic tenderness, or
costovertebral angle pain or tenderness, OR for a patient ≤ 1 year of age, no
C C
lethargy, or vomiting)
and
a positive urine culture of >105 CFU/ml with no more than 2 species of
uropathogen microorganisms**
and
a positive blood culture with at least 1 matching uropathogen microorganism
to the urine culture.

*Fever is not diagnostic for UTI in the elderly (>65 years of age) and
therefore fever in this age group does not disqualify from meeting the criteria
of an ABUTI.
**Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus
spp., yeasts, beta-hemolytic Streptococcus spp., Enterococcus spp., G.
vaginalis, Aerococcus urinae, and Corynebacterium (urease positive).
Comment • Urinary catheter tips should not be cultured and are not acceptable for the
diagnosis of a urinary tract infection.
• Urine cultures must be obtained using appropriate technique, such as clean
catch collection or catheterization. Specimens from indwelling catheters
should be aspirated through the disinfected sampling ports.
• In infants, urine cultures should be obtained by bladder catheterization or
suprapubic aspiration; positive urine cultures from bag specimens are
unreliable and should be confirmed by specimens aseptically obtained by
catheterization or suprapubic aspiration.
• Urine specimens for culture should be processed as soon as possible,
preferably within 1 to 2 hours. If urine specimens cannot be processed within
30 minutes of collection, they should be refrigerated, or inoculated into
primary isolation medium before transport, or transported in an appropriate



urine preservative. Refrigerated specimens should be cultured within 24
hours.
• Urine specimen labels should indicate whether or not the patient is
symptomatic.
• Report secondary bloodstream infection = “Yes” for all cases of
Asymptomatic Bacteremic Urinary Tract Infection (ABUTI).
• Report Corynebacterium (urease positive) as either Corynebacterium
species unspecified (COS) or, as C. urealyticum (CORUR) if so speciated.
Criterion Other Urinary Tract Infection (OUTI) (kidney, ureter, bladder, urethra, or
tissue surrounding the retroperineal or perinephric space)
Other infections of the urinary tract must meet at least 1 of the following
criteria:
1 Patient has microorganisms isolated from culture of fluid (other than urine) or
tissue from affected site.
2 Patient has an abscess or other evidence of infection seen on direct
examination, during a surgical operation, or during a histopathologic
examination.
3 Patient has at least 2 of the following signs or symptoms with no other
recognized cause: fever (>38° localized pain, or localized tenderness at
C),
the involved site
and
at least 1 of the following:
a. purulent drainage from affected site
b. microorganisms cultured from blood that are compatible with
suspected site of infection
c. radiographic evidence of infection (e.g., abnormal ultrasound, CT
scan, magnetic resonance imaging [MRI], or radiolabel scan [gallium,
technetium]).
4 Patient < 1 year of age has at least 1 of the following signs or symptoms with
no other recognized cause: fever (>38° core), hypothermia (<36° core),
C C
apnea, bradycardia, lethargy, or vomiting
and
at least 1 of the following:
a. purulent drainage from affected site
b. microorganisms cultured from blood that are compatible with
suspected site of infection
c. radiographic evidence of infection, (e.g., abnormal ultrasound, CT
scan, magnetic resonance imaging [MRI], or radiolabel scan [gallium,
technetium]).
Comment • Report infections following circumcision in newborns as SST-CIRC.

Source:



Bloodstream Infection Criteria

Laboratory-confirmed bloodstream infection (LCBI): Must meet one of the following
criteria:

Criterion 1:
Patient has a recognized pathogen cultured from one or more blood cultures
and
organism cultured from blood is not related to an infection at another site. (See Notes 1
and 2 below.)

Criterion 2:
Patient has at least one of the following signs or symptoms: fever (>38oC), chills, or
hypotension
and
signs and symptoms and positive laboratory results are not related to an infection at
another site
and
common skin contaminant (i.e., diphtheroids [Corynebacterium spp.], Bacillus [not B.
anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S.
epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is
cultured from two or more blood cultures drawn on separate occasions.

Criterion 3:
Patient < 1 year of age has at least one of the following signs or symptoms: fever
(>38oC core) hypothermia (<36oC core), apnea, or bradycardia
and
signs and symptoms and positive laboratory results are not related to an infection at
another site
and
common skin contaminant (i.e., diphtheroids [Corynebacterium spp.], Bacillus [not B.
anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S.
epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is
cultured from two or more blood cultures drawn on separate occasions. (See Notes 3, 4
and 5 below.)

NOTES:
1. In criterion 1, the phrase “one or more blood cultures” means that at least one bottle
from a blood draw is reported by the laboratory as having grown organisms (i.e., is a
positive blood culture).
2. In criterion 1, the term “recognized pathogen” does not include organisms
considered common skin contaminants (see criteria 2 and 3 for a list of common skin



contaminants). A few of the recognized pathogens are S. aureus, Enterococcus
spp., E. coli, Pseudomonas spp., Klebsiella spp., Candida spp., etc.
3. In criteria 2 and 3, the phrase “two or more blood cultures drawn on separate
occasions” means 1) that blood from at least two blood draws were collected within
two days of each other (e.g., blood draws on Monday and Tuesday or Monday and
Wednesday would be acceptable for blood cultures drawn on separate occasions,
but blood draws on Monday and Thursday would be too far apart in time to meet this
criterion), and 2) that at least one bottle from each blood draw is reported by the
laboratory as having grown the same common skin contaminant organism (i.e., is a
positive blood culture). (See Note 4 for determining sameness of organisms.)
a. For example, an adult patient has blood drawn at 8 a.m. and again at 8:15 a.m. of
the same day. Blood from each blood draw is inoculated into two bottles and
incubated (four bottles total). If one bottle from each blood draw set is positive for
coagulase-negative staphylococci, this part of the criterion is met.
b. For example, a neonate has blood drawn for culture on Tuesday and again on
Saturday and both grow the same common skin contaminant. Because the time
between these blood cultures exceeds the two-day period for blood draws
stipulated in criteria 2 and 3, this part of the criteria is not met.
c. A blood culture may consist of a single bottle for a pediatric blood draw due to
volume constraints. Therefore, to meet this part of the criterion, each bottle from
two or more draws would have to be culture-positive for the same skin
contaminant.
4. There are several issues to consider when determining sameness of organisms.
a. If the common skin contaminant is identified to the species level from one culture,
and a companion culture is identified with only a descriptive name (i.e., to the
genus level), then it is assumed that the organisms are the same. The speciated
organism should be reported as the infecting pathogen (see examples below).

Table 1. Examples of how to report speciated and unspeciated common skin
contaminate organisms
Culture Report Companion Culture Report as…
Report
S. epidermidis Coagulase-negative S. epidermidis
staphylococci
Bacillus spp. (not anthracis) B. cereus B. cereus
S. salivarius Strep viridans S. salivarius

Table 2. Examples of how to interpret the sameness of two skin contaminate
isolates by comparing antimicrobial susceptibilities
Culture Report Isolate A Isolate B Interpret as…
S. epidermidis All drugs S All drugs S Same
S. epidermidis OX R OX S Different
GENT R GENT S



Corynebacterium spp. PEN G R PEN G S Different
CIPRO S CIPRO R
Strep viridans All drugs S All drugs S Same
except
ERYTH (R)

b. If common skin contaminant organisms from the cultures are speciated but no
antibiograms are done or they are done for only one of the isolates, it is assumed
that the organisms are the same.
c. If the common skin contaminants from the cultures have antibiograms that are
different for two or more antimicrobial agents, it is assumed that the organisms
are not the same (see table below).
d. For the purpose of NHSN antibiogram reporting, the category interpretation of
intermediate (I) should not be used to distinguish whether two organisms are
different.
5. LCBI criteria 1 and 2 may be used for patients of any age, including patients < 1 year
of age.
6. Specimen Collection Considerations:
Ideally, blood specimens for culture should be obtained from two to four blood
draws from separate venipuncture sites (e.g., right and left antecubital veins), not
through a vascular catheter. These blood draws should be performed
simultaneously or over a short period of time (i.e., within a few hours).3,4 If your
facility does not currently obtain specimens using this technique, you may still
report BSIs using the criteria and notes above, but you should work with
appropriate personnel to facilitate better specimen collection practices for blood
cultures.

REPORTING INSTRUCTIONS:
• Purulent phlebitis confirmed with a positive semiquantitative culture of a catheter
tip, but with either negative or no blood culture is considered a CVS-VASC, not a
BSI.
• Report organisms cultured from blood as BSI – LCBI when no other site of
infection is evident.
• Occasionally a patient with both peripheral and central IV lines develops a
primary bloodstream infection (LCBI) that can clearly be attributed to the
peripheral line (e.g., pus at the insertion site and matching pathogen from pus
and blood). In this situation, enter ”Central Line = No” in the NHSN application.
You should, however, count the patient’s central line days.
• March, 2009 4-6 Device-associated Module CLABSI



Clinical sepsis (CSEP): Must meet the following criterion:

Patient < 1 year of age has at least one of the following clinical signs or symptoms with
no other recognized cause: fever (>38oC core), hypothermia (<36oC, core), apnea, or
bradycardia
and
blood culture not done or no organisms detected in blood
and
no apparent infection at another site
and
physician institutes treatment for sepsis.

Report culture-positive infections of the bloodstream as BSI – LCBI.

Source:



Criteria for Clinically Defined Pneumonia (PNU1)*

Table 1. Abbreviations used in PNEU laboratory criteria
BAL – bronchoalveolar lavage LRT – lower respiratory tract
EIA – enzyme immunoassay PCR – polymerase chain reaction
FAMA – fluorescent-antibody staining of PMN – polymorphonuclear leukocyte
membrane antigen
IFA – immunofluorescent antibody RIA − radioimmunoassay

• There is a hierarchy of specific categories within the major site pneumonia. Even if a
patient meets criteria for more than one specific site, report only one:
• Report concurrent lower respiratory tract infection (e.g., abscess or empyema) and
pneumonia with the same organism(s) as pneumonia
• Lung abscess or empyema without pneumonia are classified as LUNG
• Bronchitis, tracheitis, tracheobronchitis, or bronchiolitis without pneumonia are
classified as BRON.



Table 2. Specific Site Algorithms for Clinically Defined Pneumonia (PNU1)

Radiology Signs/Symptoms/Laboratory
Two or more serial FOR ANY PATIENT, at least one of the following:
chest radiographs -Fever (>38° or >100.4° with no other recognized cause
C F)
with at least one of -Leukopenia (<4000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3)
the following 1,2: -For adults >70 years old, altered mental status with no other
recognized cause
New or AND
progressive and at least two of the following:
persistent infiltrate -New onset of purulent sputum3, or change in character of sputum4, or
increased respiratory secretions, or increased suctioning requirements
Consolidation -New onset or worsening cough, or dyspnea, or tachypnea5
-Rales6 or bronchial breath sounds
Cavitation -Worsening gas exchange (e.g. O2 desaturations (e.g., PaO2/FiO2 <
240)7, increased oxygen requirements, or increased ventilator
Pneumatoceles, in demand)
infants ≤ 1 year old
ALTERNATE CRITERIA, for infants <1 year old:
Worsening gas exchange (e.g., O2 desaturations, increased oxygen
NOTE: In patients requirements, or increased ventilator demand)
without underlying AND
pulmonary or at least three of the following:
cardiac disease -Temperature instability with no other recognized cause
(e.g. respiratory -Leukopenia (<4000 WBC/mm3) or leukocytosis (>15,000 WBC/mm3)
distress syndrome, and left shift (>10% band forms)
bronchopulmonary -New onset of purulent sputum3 or change in character of sputum4, or
dysplasia, increased respiratory secretions or increased suctioning requirements
pulmonary edema, -Apnea, tachypnea5 , nasal flaring with retraction of chest wall or
or chronic grunting
obstructive -Wheezing, rales6, or rhonchi
pulmonary -Cough
disease), one -Bradycardia (<100 beats/min) or tachycardia (>170 beats/min)
definitive chest ALTERNATE CRITERIA, for child >1 year old or ≤ 12 years old, at
radiograph is least three of the following:
acceptable.1 -Fever (>38.4° or >101.1° or hypothermia (<36.5° or <97.7°
C F) C F)
with no other recognized cause
-Leukopenia (<4000 WBC/mm3) or leukocytosis (≥ 15,000 WBC/mm3)
-New onset of purulent sputum3, or change in character of sputum4, or
increased respiratory secretions, or increased suctioning requirements
-New onset or worsening cough, or dyspnea, apnea, or tachypnea5.
-Rales6 or bronchial breath sounds.
-Worsening gas exchange (e.g. O2 desaturations, increased oxygen
requirements, or increased ventilator demand)



Table 3. Specific Site Algorithms for Pneumonia with Common Bacterial or
Filamentous Fungal Pathogens and Specific Laboratory Findings (PNU2)

Radiology Signs/Symptoms Laboratory
Two or more serial At least one of the following: At least one of the following:
chest radiographs
with at least one of -Fever (>38° or >100.4°
C F) -Positive growth in blood
the following1,2: with no other recognized cause culture8 not related to another
-Leukopenia (<4000 source of infection
New or progressive WBC/mm3) or
and persistent -leukocytosis (>12,000 -Positive growth in culture of
infiltrate WBC/mm3) pleural fluid
-For adults >70 years old,
Consolidation altered mental status with no -Positive quantitative culture9
other recognized cause from minimally contaminated
Cavitation LRT specimen (e.g., BAL or
AND protected specimen brushing)
Pneumatoceles, in
infants ≤ 1 year old at least one of the following: -≥ 5% BAL-obtained cells
contain intracellular bacteria on
-New onset of purulent direct microscopic exam (e.g.,
NOTE: In patients sputum3, or Gram stain)
without underlying -change in character of
pulmonary or sputum4, or -Histopathologic exam shows
cardiac disease (e.g. -increased respiratory at least one of the following
respiratory distress secretions, or evidences of pneumonia:
syndrome, -increased suctioning -Abscess formation or foci of
bronchopulmonary requirements consolidation with intense PMN
dysplasia, accumulation in bronchioles
pulmonary edema, -New onset or worsening and alveoli
or chronic cough, or dyspnea or -Positive quantitative culture9
obstructive tachypnea5 of lung parenchyma Evidence
pulmonary disease), of lung parenchyma invasion by
one definitive chest -Rales6 or bronchial breath fungal hyphae or
radiograph is sounds pseudohyphae
acceptable.1
-Worsening gas exchange (e.g.
O2 desaturations [e.g.,
PaO2/FiO2 < 240]7, increased
oxygen requirements, or
increased ventilator demand)



Table 4. Specific Site Algorithms for Viral, Legionella, and other Bacterial
Pneumonias with Definitive Laboratory Findings (PNU2)

Two or more serial At least one of the following: At least one of the following10-
12
chest :
radiographs with at -Fever (>38° or >100.4°
C F)
least one of the with no other recognized cause -Positive culture of virus or
following1,2: -Leukopenia (<4000 Chlamydia from respiratory
WBC/mm3) or secretions
New or progressive -leukocytosis (>12,000
and persistent WBC/mm3) -Positive detection of viral
infiltrate -For adults >70 years old, antigen or antibody from
altered mental status with no respiratory secretions (e.g.,
Consolidation other EIA, FAMA, shell vial
recognized cause assay, PCR)
Cavitation
AND -Fourfold rise in paired sera
Pneumatoceles, in (IgG) for pathogen (e.g.,
infants at least one of the following: influenza viruses, Chlamydia)
≤ 1 year old -New onset of purulent
sputum3, or -Positive PCR for Chlamydia or
change in character of Mycoplasma
NOTE: In patients sputum4, or
without underlying increased respiratory -Positive micro-IF test for
pulmonary or secretions, or Chlamydia
cardiac disease (e.g. increased suctioning
respiratory requirements -Positive culture or visualization
distress syndrome, by micro-IF of Legionella spp,
bronchopulmonary -New onset or worsening cough from respiratory secretions or
dysplasia, or dyspnea, or tachypnea5 tissue.
pulmonary
edema, or chronic -Rales6 or bronchial breath -Detection of Legionella
obstructive sounds pneumophila serogroup 1
pulmonary disease), antigens in urine by RIA or EIA
one definitive -Worsening gas exchange (e.g.
chest radiograph is O2 desaturations [e.g., -Fourfold rise in L. pneumophila
1
acceptable. PaO2/FiO2 < 240]7, increased serogroup 1antibody titer to ≥
oxygen requirements, or 1:128 in paired acute and
increased ventilator demand) convalescent sera by indirect
IFA.



Table 5. Specific Site Algorithm for Pneumonia in Immunocompromised Patients
(PNU3)

Two or more serial Patient who is At least one of the following:
chest radiographs immunocompromised13 has at
with at least one of least one of the following: -Matching positive blood and
the following1,2: sputum cultures with Candida
-Fever (>38° or >100.4°
C F) spp. 14, 15
New or progressive with no other recognized cause
and persistent -Evidence of fungi or
infiltrate -For adults >70 years old, Pneumocystis carinii from
altered mental status with no minimally contaminated LRT
Consolidation other recognized cause specimen (e.g., BAL or
protected specimen brushing)
Cavitation -New onset of purulent from one of the following:
sputum3, or - Direct microscopic exam
Pneumatoceles, in change in character of - Positive culture of fungi
infants ≤ 1 year old sputum4, or
increased respiratory Any of the following from
secretions, or
NOTE: In patients increased suctioning LABORATORY CRITERIA
without underlying requirements DEFINED UNDER PNU2
pulmonary or
cardiac disease (e.g. -New onset or worsening
respiratory distress cough, or dyspnea, or
syndrome, tachypnea5
bronchopulmonary
dysplasia, -Rales6 or bronchial breath
pulmonary edema, sounds
or chronic
obstructive -Worsening gas exchange (e.g.
pulmonary disease), O2 desaturations [e.g.,
one definitive chest PaO2/FiO2 < 240]7, increased
radiograph is oxygen requirements, or
acceptable.1 increased ventilator demand)

-Hemoptysis

-Pleuritic chest pain



Footnotes to Algorithms:
1. Occasionally, in nonventilated patients, the diagnosis of healthcare-associated
pneumonia may be quite clear on the basis of symptoms, signs, and a single
definitive chest radiograph. However, in patients with pulmonary or cardiac
disease (for example, interstitial lung disease or congestive heart failure), the
diagnosis of pneumonia may be particularly difficult. Other non-infectious
conditions (for example, pulmonary edema from decompensated congestive
heart failure) may simulate the presentation of pneumonia. In these more difficult
cases, serial chest radiographs must be examined to help separate infectious
from non-infectious pulmonary processes. To help confirm difficult cases, it may
be useful to review radiographs on the day of diagnosis, 3 days prior to the
diagnosis and on days 2 and 7 after the diagnosis. Pneumonia may have rapid
onset and progression, but does not resolve quickly. Radiographic changes of
pneumonia persist for several weeks. As a result, rapid radiographic resolution
suggests that the patient does not have pneumonia, but rather a non-infectious
process such as atelectasis or congestive heart failure.
2. Note that there are many ways of describing the radiographic appearance of
pneumonia. Examples include, but are not limited to, “air-space disease”, “focal
opacification”, “patchy areas of increased density”. Although perhaps not
specifically delineated as pneumonia by the radiologist, in the appropriate clinical
setting these alternative descriptive wordings should be seriously considered as
potentially positive findings.
3. Purulent sputum is defined as secretions from the lungs, bronchi, or trachea that
contain >25 neutrophils and <10 squamous epithelial cells per low power field
(x100). If your laboratory reports these data qualitatively (e.g., “many WBCs” or
“few squames”), be sure their descriptors match this definition of purulent
sputum. This laboratory confirmation is required since written clinical descriptions
of purulence are highly variable.
4. A single notation of either purulent sputum or change in character of the sputum,
is not meaningful; repeated notations over a 24 hour period would be more
indicative of the onset of an infectious process. Change in character of sputum
refers to the color, consistency, odor and quantity.
5. In adults, tachypnea is defined as respiration rate >25 breaths per minute.
Tachypnea is defined as >75 breaths per minute in premature infants born at <37
th
weeks gestation and until the 40 week; >60 breaths per minute in patients <2
months old; >50 breaths per minute in patients 2-12 months old; and >30 breaths
per minute in children >1 year old.
6. Rales may be described as “crackles”.
7. This measure of arterial oxygenation is defined as the ratio of the arterial tension
(PaO2) to the inspiratory fraction of oxygen (FiO2).
8. Care must be taken to determine the etiology of pneumonia in a patient with
positive blood cultures and radiographic evidence of pneumonia, especially if the
patient has invasive devices in place such as intravascular lines or an indwelling
urinary catheter. In general, in an immunocompetent patient, blood cultures
positive for coagulase negative staphylococci, common skin contaminants, and
yeasts will not be the etiologic agent of the pneumonia.



9. Refer to Threshold values for cultured specimens (Table 6). An endotracheal
aspirate is not a minimally contaminated specimen. Therefore, an endotracheal
aspirate does not meet the laboratory criteria.
10. Once laboratory-confirmed cases of pneumonia due to respiratory syncytial virus
(RSV), adenovirus, or influenza virus have been identified in a hospital, clinician’s
presumptive diagnosis of these pathogens in subsequent cases with similar
clinical signs and symptoms is an acceptable criterion for presence of healthcare-
associated infection.
11. Scant or watery sputum is commonly seen in adults with pneumonia due to
viruses and Mycoplasma although sometimes the sputum may be mucopurulent.
In infants, pneumonia due to RSV or influenza yields copious sputum. Patients,
except premature infants, with viral or mycoplasmal pneumonia may exhibit few
signs or symptoms, even when significant infiltrates are present on radiographic
exam.
12. Few bacteria may be seen on stains of respiratory secretions from patients with
pneumonia due to Legionella spp, mycoplasma, or viruses.
13. Immunocompromised patients include those with neutropenia (absolute
3
neutrophil count <500/mm ), leukemia, lymphoma, HIV with CD4 count <200, or
splenectomy; those who are early post-transplant, are on cytotoxic
chemotherapy, or are on high dose steroids (e.g., >40mg of prednisone or its
equivalent (>160mg hydrocortisone, >32mg methylprednisolone, >6mg
dexamethasone, >200mg cortisone) daily for >2weeks).
14. Blood and sputum specimens must be collected within 48 hours of each other.
15. Semiquantitative or nonquantitative cultures of sputum obtained by deep cough,
induction, aspiration, or lavage are acceptable. If quantitative culture results are
available, refer to algorithms that include such specific laboratory findings.

Source:



Appendix G

The Practice Environment Scale of the Nursing Work Index (PES-NWI)

Subscales and Component Items

Subscale Component items
Mean score on a composite of all subscale scores Subscale scores

Nurse Participation in Hospital Affairs 5, 6, 11, 15, 17, 21, 23, 27, 28

4, 14, 18, 19, 22, 25, 26, 29,
Nursing Foundations for Quality of Care
30, 31
Nurse Manager Ability, Leadership, and Support of
3, 7, 10, 13, 20
Nurses
Staffing and Resource Adequacy 1, 8, 9, 12
Collegial Nurse-Physician Relations 2, 16, 24
Three category variable indicating favorable, mixed, or
Subscale scores
unfavorable practice environments

Scoring Directions
For hospital-level scores, calculate the item-level mean first from all responses. Then
proceed with the standard computation for subscale scores. This approach permits all
nurse responses, including responses of nurses who did not answer all items, to be
included in the hospital score.

For nurse-specific subscale scores, calculate the mean of the items in the subscale.
The mean permits easy comparison across subscales.

Calculate an overall PES-NWI “composite” score as the mean of the five subscale
scores. This approach gives equal weight to the subscales, rather than to the items.

Three category variable indicating favorable, mixed, or unfavorable practice
environments:
Favorable = four or more subscale means exceed 2.5;
Mixed = two or three subscale means exceed 2.5;
Unfavorable = zero or one subscales exceed 2.5.

Source: Used with permission. Eileen T. Lake. “Development of the Practice
Environment Scale of the Nursing Work Index.” Research in Nursing & Health,
May/June 2002; 25(3): 176-188.

NSC Measure Set Appendix G-1


The Practice Environment Scale of the Nursing Work Index

For each item, please indicate the extent to which you agree that the item is PRESENT
IN YOUR CURRENT JOB. Indicate your degree of agreement by circling the
appropriate number.

Strongly Agree Disagree Strongly
Agree Disagree

1 Adequate support services allow me to 4 3 2 1
spend time with my patients.

2 Physician and nurses have good 4 3 2 1
working relationships.

3 A supervisory staff that is supportive of 4 3 2 1
the nurses.

4 Active staff development or continuing 4 3 2 1
education programs for nurses.

5 Career development/clinical ladder 4 3 2 1
opportunity.

6 Opportunity for staff nurses to 4 3 2 1
participate in policy decisions.

7 Supervisors use mistakes as learning 4 3 2 1
opportunities, not criticism.

8 Enough time and opportunity to discuss 4 3 2 1
patient care problems with other
nurses.

9 Enough registered nurses to provide 4 3 2 1
quality patient care.
10 A nurse manager who is a good 4 3 2 1
manager and leader.

11 A chief nursing office who is highly 4 3 2 1
visible and accessible to staff.

12 Enough staff to get the work done. 4 3 2 1

13 Praise and recognition for a job well 4 3 2 1
done.



14 High standards of nursing care are 4 3 2 1
expected by the administration.

15 A chief nurse officer equal in power and 4 3 2 1
authority to other top-level hospital
executives.

16 A lot of team work between nurses and 4 3 2 1
physicians.

17 Opportunities for advancement. 4 3 2 1

18 A clear philosophy of nursing that 4 3 2 1
pervades the patient care environment.

19 Working with nurses who are clinically 4 3 2 1
competent.

20 A nurse manager who backs up the 4 3 2 1
nursing staff in decision making, even if
the conflict is with a physician.

21 Administration that listens and 4 3 2 1
responds to employee concerns.

22 An active quality assurance program. 4 3 2 1

23 Staff nurses are involved in the internal 4 3 2 1
governance of the hospital (e.g.,
practice and policy committees).

24 Collaboration (joint practice) between 4 3 2 1
nurses and physicians.

25 A preceptor program for newly hired 4 3 2 1
RNs.

26 Nursing care is based on a nursing, 4 3 2 1
rather than a medical, model.

27 Staff nurses have the opportunity to 4 3 2 1
serve on hospital and nursing
committees.

28 Nursing administrators consult with staff 4 3 2 1



on daily problems and procedures.

29 Written, up-to-date nursing care plans 4 3 2 1
for all patients.

30 Patient care assignments that foster 4 3 2 1
continuity of care, i.e., the same nurse
cares for the patient from one day to
the next.

31 Use of nursing diagnoses. 4 3 2 1

Source: Used with permission. Eileen T. Lake. “Development of the Practice
Environment Scale of the Nursing Work Index.” Research in Nursing & Health,
May/June 2002; 25(3): 176-188.


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