NSQI Definitions PDF

Nursing-Sensitive
Measure Definitions
Implementation Guide for the NQF Endorsed
Nursing-Sensitive Care Performance Measures
Pressure Ulcer
Prevalence
Available at:
www.JointCommission.org/PerformanceMeasurement/MeasureReserveLibrary/nqf_nursing.htm
The Implementation Guide for the NQF Endorsed Nursing-Sensitive Care Performance Measures,
[Version 1.00, December, 2005] is the intellectual property of and copyrighted by the Joint Commission on
Accreditation of Healthcare Organizations, Oakbrook Terrace, Illinois.
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All rights reserved.
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not granted herein should be addressed to:
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Pressure Ulcer Prevalence, From the Joint Commission's "Implementation Guide for the NQF
Endorsed Nursing-Sensitive Care Performance Measures", see:
http://www.jointcommission.org/PerformanceMeasurement/MeasureReserveLibrary/nqf_nursing.htm
Release Notes:
Measure Information Form –
Version 1.00 (NSC)
**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR NURSING-SENSITIVE CARE

PERFORMANCE MEASURES**
Measure Information Form

Measure Set: Nursing-Sensitive Care
Performance Measure ID: NSC-2
Performance Measure Name: Pressure Ulcer Prevalence
Description: The total number of patients that have nosocomial (hospital-acquired) 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.
Type of Measure: Outcome
Improvement Noted as: Decrease in rate
Numerator Statement: Patients surveyed on an eligible reporting unit that have at least
one stage II or greater [National Ulcer Advisory Panel (NPUAP)] nosocomial pressure
ulcer on the day of the prevalence study.
Included Populations:
• Hospital Acquired Pressure Ulcers – Pressure Ulcers of Stage II or greater
AND the Day of First Staff Discovery/Documentation of Pressure Ulcer is
greater than or equal to 0003.
Implementation Guide for the NQF NSC 2 - 1 Joint Commission, 2005

Endorsed Nursing-Sensitive Care
Performance Measures
Excluded Populations:
• Patients with skin breakdown due to arterial occlusion, venous
insufficiency, diabetes related neuropathy, or incontinence dermatitis.
• Patients with NO ulcers greater than stage I on the day of the prevalence
study.
• Patients with an ulcer (any stage) present on the patient’s first day in the
hospital.
• Patients with ulcers greater than Stage I on the day of the prevalence study
where ALL the ulcers were documented to be present on day 2 of the
patient’s hospitalization.
Data Elements:
Day of First Staff Discovery/Documentation of Pressure Ulcer
Day of Hospitalization for Patient on Prevalence Study Day
Observed Pressure Ulcer
Observed Pressure Ulcer – Hospital Acquired
Observed Pressure Ulcer - Stage
Denominator Statement:
All patients on the selected unit at the time of the study who are surveyed for the study by
Type of Unit.
Included Populations: Patients 18 years or older who are admitted to medical,

surgical, medical-surgical combined, critical care, and step-down units that are
surveyed for the study.
• Patients less than 18 years of age
Data Elements:
Admission Date
Birthdate
Month
Year
Risk Adjustment/Stratification: Yes
Data Elements:
Type of Unit
Data Collection Approach: Concurrent for required data elements and retrospective for
optional data elements.

Data Accuracy:
• Review and follow the Prevalence Study Methodology (see Appendix D)
• For the purposes of this measure, and to maximize reliability across organizations,
only hospital-acquired 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 stage II or greater observed on day 3 or later of the patient’s
hospitalization AND for which there is no documentation in the record
indicating the day of first discovery; should be considered as nosocomial.
• Pressure Ulcer Stage: (NPUAP-AHCPR Ulcer Stages I-IV)
Stage I Non blanching erythema of intact skin
Stage II Partial thickness involving epidermis and/or dermis; superficial
and presents clinically as an abrasion, blister, or shallow crater
Stage III Full thickness skin loss involving damage or necrosis of
subcutaneous tissue that may extend down to, but not through,
underlying fascia; presents clinically as a deep crater with or
without undermining of adjacent tissue
Stage IV Full thickness skin loss with extensive destruction, tissue necrosis
or damage to muscle, bone or supporting tissues (e.g., tendon or
joint capsule)
Eschar Unable to stage
Measure Analysis Suggestions: In order to further examine the issue of pressure ulcers
within your facility it may be useful to analyze the pressure ulcer rate by other important
factors. For example, it may be valuable to calculate the rate of risk assessments
completed and use of prevention protocols. To facilitate these analyses, optional data
elements have been added to the data collection tool. These include, but are not limited to
risk assessment and prevention actions. These data are not required to calculate the basic
prevalence rate but may be useful to further understanding of your organization’s
pressure ulcer prevalence and initiate quality improvement activities if appropriate.
Terminology:
Community Acquired Pressure Ulcer A community acquired pressure ulcer is
defined by:
• Ulcer discovered/documented on first day of hospitalization; or
• Prevalence study was done on day one of patient’s hospital stay and ulcer
was already present; or
• Ulcer of Stage II or greater discovered/documented on second day of
hospitalization; or
• Prevalence study was done on day two pf patient’s hospital stay and a
Stage II or greater ulcer was already present.
Hospital Acquired Pressure Ulcer (Nosocomial) Nosocomial refers to new

ulcer(s) developed after admission to a facility (also termed hospital-acquired).
All pressure ulcers not meeting the community-acquired criteria should be
designated as hospital-acquired pressure ulcers.
Pressure Ulcer Any lesion caused by unrelieved pressure resulting in damage of
underlying tissue. They may be located over bony prominences or under a
medical device/equipment. They are staged according to the extent of observable
tissue damage.
Optional Data Elements:

Admission Pressure Ulcer Risk Assessment
Braden Risk Assessment
Braden Subscale Score-Activity
Braden Subscale Score-Friction
Braden Subscale Score-Mobility
Braden Subscale Score-Moisture
Braden Subscale Score-Nutrition
Braden Subscale Score-Sensory
Braden Total Score
BUN
Creatinin
Other Risk Assessment Score
Pressure Ulcer Prevention Protocol
Pressure Ulcer Risk
Primary Reason for Hospitalization
Serum Albumin
Serum Prealbumin
Sampling: Prevalence Study Methodology
Age Groups: Age 18 years and older
Data Reported as: Aggregate rate generated from count data reported as a proportion
Selected References:
• Gerson LW. The incidence of pressure sores in active treatment hospitals. Int J
Nurs Stud. 1975:12(4):201-4.
• Clarke M, Kadholm HM. The nursing prevention of pressure sores in hospital and
community patients. J Adv Nurs. 1988 May;13(3):365-73.
• Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline
Number 3. AHCPR Pub. No. 92-0047:May 1992
• Bergstrom, N., Braden, B., Kemp, M., Champagne, M., & Ruby, E. (1998).
Predicting pressure ulcer risk- A multisite study of the predictive validity of the
Braden Scale, Nurs Res, 47(5), 261-269.
• Wound, Ostomy and Continence Nurses Society. (2003) Guideline for Prevention
and Management of Pressure Ulcers. WOCN: Glenview, IL
• Bergstrom N, Braden BJ, Laguzsza A, Holman V. The Braden scale for predicting
pressure sore risk. Nurs Res, 1987: Vol. 36:205-210.

• 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:
Vol. 105:70-72.
• Schoonhoven L, Haalboom JRE, Bousema MT, et al., Prospective cohort study of
routine use of risk assessment scales for prediction of pressure ulcers. BMJ, 2002;
325:797.
• Pressure ulcers prevalence, cost and risk assessment: consensus development
conference statement- The National Pressure Ulcer Advisory Panel. Decubitus.
1989. May;2(2):24-8.

: Inpatient surveyed on the selected unit that have a at least one stage II or greater
nosocomial pressure ulcer on the day of the prevalence study.
: All patients on the selected unit at the time of the study who have not been
discharged and are surveyed for the study by Type of Unit.
:
START Patient Age
NSC-2
Missing /
A
Invalid
Valid
NSC2b Critical Care 01
NSC2c Step-down 02
NSC-2 NSC2d Medical 03
Missing /
A NSC2e Surgical 04
Invalid NSC2f Med-Surg Combined 05
Valid * This refers to the data element

‘ ’. Each case will be
(in years) = stratified according to the allowable
minus value for that .
NSC-2 Age > or = 0 days NSC-2

Age < 0
A Patient Age And Age < 18 B
days
years
>= 18
NSC-2
Missing /
A
Invalid
01,02,03,04,05,06,07,08,09,10,11
,12
NSC-2 NSC-2
Missing / < 0 or >
A B
Invalid 9999
>= 0 and <=

9999
NSC-2 Not = NSC-2

Missing /
A 01,02, B
Invalid
03, 04, 05
= 01, 02, 03, 04,

05
NSC-2 NSC-2
Missing /
C = 00 D
Invalid
=
01,02,03,04,05,06,07,08
NSC-2
H

NSC-2
H
NSC-2 Day of Hospitalization NSC-2

Missing /
C for Patient on = 0001 D
Invalid Prevalence Study Day
> 0001
Day of Hospitalization
for Patient on = 0002
Prevalence Study Day
NSC-2 Missing / = 02, 03, NSC-2

C Invalid for OPU -Stage 04, 05 for D
> 0002 all ulcers any ulcers
= 01 for all ulcers
NSC-2 Missing/Invalid NSC-2

C OPU – HA = N for all ulcers D
for all ulcers
= Y for any observed ulcers Note: At this stage, the value of ‘Day
Note: Only check OPU – Stage for ulcers of first staff discovery/documentation
whose OPU – HA = Y. of pressure ulcer’ has to be greater
than or equal to ‘0003’.
NSC-2 Missing/Invalid
C OPU – Stage = 02, 03, 04, 05 for any ulcers
for all ulcers
= 01 for all ulcers

NSC-2 In Numerator
D
Population
NSC-2
In Measure
I
Population
NSC-2 NSC-2 NSC-2

C B A
Missing or Invalid
Missing or Invalid Not In Measure
Measure Population
Numerator Data Population
Data
NSC-2 NSC-2 NSC-2

I I I

NSC-2
I
Set for the strata measure

Type of Unit = 01
NSC – 2b
= 02, 03, 04, 05

Type of Unit = 02
NSC – 2c
= 03, 04, 05

Type of Unit = 03
NSC – 2d
= 04, 05

Type of Unit = 04
NSC – 2e

= 05
NSC – 2f
STOP

Patient Falls
Available at:
Patient Falls, From the Joint Commission's "Implementation Guide for the NQF Endorsed Nursing-
Sensitive Care Performance Measures", see:
Release Notes:
Version 1.00 (NSC)


Performance Measure Name: Patient Falls
Description: All documented falls with or without injury, experienced by patients on an

eligible unit 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.
Improvement Noted as: A decrease in the rate.
Numerator Statement: Number of patient falls, with or without injury to the patient, by
Type of Unit during the calendar month x 1000.
Included Populations: Patient falls occurring while on an eligible reporting unit.
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)

Data Elements:
Month
Number of Patient Falls
Year
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 medical, surgical, medical-surgical combined, critical care, step-
down units.
Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, etc)
Data Elements:
Month
Patient Days
Year
Data Elements:
Type of Unit
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:
• “Fall Risk” Each facility should establish which patients are at risk based
on their particular screening process or assessment tool. For example, in
the literature, a cut-off score for the Morse scale is > 45 and < 3 for the
Schmid. However, your facility may select a different risk level to fit the
needs of your patient population. In addition, some facilities may not
require calculation of a risk score on low risk patients. In this case, the
scale score will not be available.
• 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 are
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 F: Table 3.1 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. These data
elements are listed below and may be useful in further analysis.
Terminology:
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.
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.
Fall Risk Assessment A formal evaluation of a patient’s likelihood to experience

a fall. Several assessment instruments are available in the literature. Two
commonly used instruments are the Morse and Schmid Scales. Organizations
often adapt or create different scales depending on population needs.
Fall Risk A defined level at which patients are determined to be “at risk” of
experiencing a fall. For example, in the literature a cut-off score for the Morse
scale is > 45 and ≥3 for the Schmid. However, an organization may select a
different risk level to fit the needs of their patients and may not require a
calculation of a risk score on low risk patients
Fall Injury Level The extent of injury experienced by a patient following a fall.
National standards for injury levels have yet to be established; therefore the
following designations are used for the purposes of the measures set.
• None – patient had no injuries resulting from the fall
• Minor – resulted in application of a dressing, ice, cleaning of a wound,
limb elevation, or topical medication
• Moderate – resulted in suturing, application of steri-strips/skin glue, or
splinting
• Major - resulted in surgery, casting, traction, or required consultation for
neurological or internal injury
• Death – the patient died as a result of injuries sustained from the fall
Fall Prevention Protocol Facility specific plan of care for the prevention of falls.
NDNQI does not mandate specific characteristics of a fall prevention protocol.
Repeat Fall More than one fall by the same patient after admission to a unit may
be classified as a repeat fall.
Optional Data Elements

Fall Assisted by Employee
Fall Prevention Protocol
Fall Risk Assessment Scale
Patient at Fall Risk
Physical Restraint
Prior Falls This Month
Risk Assessment Prior to Fall
Scale Score
Time Since Last Risk Assessment
Sampling: No
Age Groups: Any age patient on an eligible reporting unit is included in the patient day
count.
Data Reported as: Rate of patient falls per 1,000 patient days stratified by type of unit.
A quarterly rate may be determined by calculating a monthly rate for each unit, summing
the monthly rates in a quarter and dividing by 3 to produce a quarterly average.
• ANA. National Database of Nursing Quality Indicators. (NDNQI)

ANA. Nurse Staffing and Patient Outcomes in the Inpatient Setting.
Washington,DC: American Nurses Publishing; 1996.
• McCollam, M.E. (1995). “Evaluation and Implementation of a research-based
falls assessment innovation.” Nursing Clinics of North America 30(3): 507-514.
• Morse, J.M., Morse, et al. (1989). “Development of a scale to identify the fall-
prone patient.” Canadian Journal of Aging (8): 366-377.
• NDNQI. Guidelines for Data Collection and Submission on Quarterly Indicators,
Version 5.0. Kansas City, KS: The University of Kansas School of Nursing;
January, 2005.
• Schmid, N. A. (1990). “1989 Federal Nursing Service Award Winner. Reducing
patient falls: a research-based comprehensive fall prevention program.” Military
Medicine 155 (5): 202-207

: Number of patient falls by Type of Unit during the calendar month * 1000
: Patient days by Type of Unit during the calendar month
START

NSC3c Step-down 02
NSC3d Medical 03
NSC3e Surgical 04
NSC-3 Missing / NSC3f Med-Surg Combined 05
a1 Invalid
=01,02,03,04,05,0
6,
07,08,09,10,11,12 * This refers to the data element
‘ ’. Each case will be
Missing / stratified according to the allowable
NSC-3 Invalid / value for that .
a1 <0/
> 9999
>= 0 and <=
9999
Missing /
Invalid /
NSC-3 Not = 01, 02,
a1 03,
04, 05
= 01, 02, 03, 04,

05
Missing or Invalid Missing /

Measure Population Invalid or
Data < 0 or = 0
>0
Missing /
Missing or Invalid
NSC-3 Invalid or
Numerator Data
Z <0
>= 0 NSC-3
Z
NSC-3
H

NSC-3
H

=
= 01 x 1000 /
= 02, 03, 04, 05

=
= 02 x 1000 /
= 03, 04, 05

=
= 03 x 1000 /
= 04, 05

=
= 04 x 1000 /

=
= 05 x 1000 /
NSC-3
Z STOP

Falls with Injury
Available at:
Falls with Injury, From the Joint Commission's "Implementation Guide for the NQF Endorsed
Nursing-Sensitive Care Performance Measures", see:
Release Notes:
Version 1.00 (NSC)

Performance Measure Name: Falls with Injury
Description: All documented patient falls with an injury level of minor 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.
Improvement Noted as: A decrease in the rate.
Numerator Statement: Number of patient falls with an injury level of minor or greater
by Type of Unit during the calendar month x 1,000.
• Patient falls occurring while on an eligible reporting unit
• An injury level of minor or greater defined as:
o None-patient had no injuries resulting from the fall
o Minor – results in application of a dressing, ice, cleaning of a
wound, limb elevation, or topical medication
o Moderate – results in suturing, application of steri-strips/skin glue,
or splinting
o Major – results in surgery, casting, traction, or required
consultation for neurological or internal injury
o Death – results in death as a result of the fall.
Falls by:
• Visitors
Implementation Guide for the NQF NSC 4 -1 Joint Commission, 2005
• 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 with an injury level of “none”
• Falls by persons who are not patients, e.g., hospital staff, visitors.
• Falls on other unit types (e.g., pediatric, obstetrical, rehab, etc)
Data Elements:
Month
Number of Injury Falls
Year
Denominator Statement: Patient days by Type of Unit during the calendar month.
• Inpatient, short stay patients, observation patients and same day surgery
patients who receive care on in-patient units for all or part of a day.
• Adult medical, surgical, medical-surgical combined, critical care, step-
down units.
Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, etc.)
Data Elements:
Month
Patient Days
Year
Data Elements:
Type of Unit
Data Collection Approach: Retrospective – data source for required data elements
include medical records, 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 nursing staff,
the extent of injury may not yet be known. A method to follow up on the
patient’s condition at least 24 hours later should be established, as Fall
Injury Level is a required data element to determine this measure
population.
• 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 calculate 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 F: Table 3.1 Patient Day Reporting Methods).
• 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 data element Number of Injury Falls which is required
for rate calculation and provides the opportunity to further analyze fall injuries by
severity.
Terminology:
Fall Injury Level The extent of injury experienced by a patient following a fall.
National standards for injury levels have yet to be established; therefore the
following designations are used for the purposes of the measures set.
• None – patient had no injuries resulting from the fall
• Minor – resulted in application of a dressing, ice, cleaning of a wound,
limb elevation, or topical medication
• Moderate – resulted in suturing, application of steri-strips/skin glue, or
splinting
• Major - resulted in surgery, casting, traction, or required consultation for
neurological or internal injury
• Death – the patient died as a result of injuries sustained from the fall
Other Data Elements:

Fall Injury Level
Sampling: No
Age Groups: Any age patient on an eligible unit is included
Data Reported as: Rate of falls with injury per 1,000 patient days stratified by type of
unit.
A quarterly rate may be determined by calculating a monthly rate for each unit, summing
the monthly rates in a quarter and dividing by 3 to produce a quarterly average.
• ANA. National Database of Nursing Quality Indicators. (NDNQI)
ANA. Nurse Staffing and Patient Outcomes in the Inpatient Setting.
Washington,DC: American Nurses Publishing; 1996.
• McCollam, M.E. (1995). “Evaluation and Implementation of a research-based
falls assessment innovation.” Nursing Clinics of North America 30(3): 507-514.
• Morse, J.M., Morse, et al. (1989). “Development of a scale to identify the fall-
prone patient.” Canadian Journal of Aging (8): 366-377.
January, 2005.
• Schmid, N. A. (1990). “1989 Federal Nursing Service Award Winner. Reducing
patient falls: a research-based comprehensive fall prevention program.” Military
Medicine 155 (5): 202-207

JCAHO: NSC-4 Patient Falls with Injury
Numerator: Number of patient falls with an injury level minor or greater by Type of Unit during the calendar month * 1000
Denominator: Patient days by Type of Unit during the calendar month
Stratification Table:
START
Set# Stratified By *Type of Unit
NSC4c Step-down 02
NSC4d Medical 03
NSC4e Surgical 04
NSC4f Med-Surg Combined 05
NSC-4 Missing /
Month
a1 Invalid
= 01,02,03,04,05,06, * This refers to the data element ‘Type of

07,08,09,10,11,12 Unit’. Each case will be stratified
according to the allowable value for that
Type of Unit.
Missing /
NSC-4 Invalid /
Year
a1 <0/
> 9999
>= 0 and <= 9999

NSC-4
Missing /
a1
Invalid /
Type of Unit
Not = 01, 02,
03, 04, 05
= 01, 02, 03, 04, 05

Measure Population Invalid or Patient Days
Data < 0 or = 0
>0
NSC-4 Missing /
Number of
Z Invalid or
Injury Falls
<0
Missing or Invalid
Numerator Data
>= 0
NSC-4 NSC-4
H Z

NSC-4
H

=
= 01 x 1000 /
= 02, 03, 04, 05

=
= 02 x 1000 /
= 03, 04, 05

=
= 03 x 1000 /
= 04, 05

=
= 04 x 1000 /

=
= 05 x 1000 /
NSC-4
Z STOP

Skill Mix
Available at:
Skill Mix, From the Joint Commission's "Implementation Guide for the NQF Endorsed Nursing-
Sensitive Care Performance Measures", see:
Release Notes:
Measure Information Form – Version 1.00 (NSC)

Performance Measure Identifier: NSC-12

Set Measure ID# Measure Population
NSC-12.1 Hours worked by RN
nursing staff
NSC-12.2 Hours worked by
LVN/LPN staff
NSC-12.3 Hours worked by UAP staff
NSC-12.4 Hours worked by Contract
staff (RN, LVN/LPN, and
UAP)
Performance Measure Name: Skill Mix
NSC – 12.1 Skill Mix - Registered Nurse (RN) staff

NSC – 12.2 Skill Mix – Licensed Vocational Nurse (LVN)/ Licensed Practical Nurse (LPN) staff
NSC - 12.3 Skill Mix - Unlicensed Assistive Personnel (UAP)
NSC - 12.4 Skill Mix - Contract staff
Description:
NSC-12.1 Percentage of hours worked by RN nursing staff (employee and contract) with patient care
responsibilities by type of unit
NSC-12.2 Percentage of hours worked by LVN/LPN staff (employee and contract) with patient care
NSC-12.3 Percentage of hours worked by UAP staff (employee and contract) with patient care
NSC-12.4 Percentage of hours worked by contract staff (RN, LVN/LPN LVN/LPN, and UAP) with
patient care responsibilities by type of unit
Rationale: The skill mix of the nursing staff, typically expressed as the ratio of RNs (LPNs/LVN,s 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 as specified in the Set Measure Identifier and
Description above
NSC-12.1 NSC-12.2 NSC-12.3 NSC-12.4
Included Productive hours worked Productive hours worked by Productive hours worked Productive hours worked
Populations by RN staff with direct LVN/LPN staff with direct by unlicensed assistive by contract staff (RN,
patient care patient care responsibilities personnel (UAP) staff LVN/LPN, and UAP)
responsibilities for for greater than 50% of their with direct patient care with direct patient care
greater than 50% of their shift. Include: responsibilities for greater responsibilities for greater
shift. Include: • Staff who are than 50% of their shift. than 50% of their shift.
• Staff who are counted in the Include: Include:
counted in the staffing matrix, and • Staff who are • Staff not
staffing matrix, • Who are replaced if counted in the employed by
and they call in sick., staffing matrix, your facility
• Who are and and • Staff hired on a
replaced if they • Work hours are • Who are contractual basis
call in sick, and charged to the replaced if they to fill staffing
• Work hours are unit’s cost center call in sick, and needs for a
charged to the • Contract staff • Work hours are designated shift
unit’s cost charged to the or on another
center unit’s cost center short-term basis
• Contract staff • Contract staff • 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
Excluded • Persons whose • Persons whose • Persons whose • Persons whose
Populations primary primary primary primary
responsibility is responsibility is responsibility is responsibility is
administrative administrative in administrative in administrative in
in nature nature nature nature
• Specialty teams, • Specialty teams, • Specialty teams, • Specialty teams,
patient patient educators or patient educators patient educators
educators or case managers who or case managers or case managers
case managers are not assigned to who are not who are not
who are not a specific unit. assigned to a assigned to a
assigned to a specific unit. specific unit.
specific unit. • Unit secretary,
monitor techs
Data RN Hours [Contract: LPN and LVN Hours UAP Hours LPN and LVN Hours
Elements Agency] [Contract:Agency] [Contract:Agency] [Contract:Agency]
RN Hours [Employee] LPN and LVN Hours UAP Hours [Employee] RN Hours
[Employee] [Contract:Agency]
UAP Hours
[Contract:Agency]
Denominator Statement: Total number of productive hours worked by nursing staff [RN, LVN/LPN, UAP
(employee and contract)] with patient care responsibilities by Type of Unit during the calendar month
Data Elements:
LPN and LVN Hours [Contract:Agency]
LPN and LVN Hours [Employee]
Month
RN Hours [Contract:Agency]
RN Hours [Employee ]
UAP Hours [Contract:Agency]
UAP Hours [Employee]
Year
Included Populations: Adult medical, surgical, medical-surgical combined, critical care, step-down
units.
Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, etc)
NSC NSC NSC NSC

12.1 12.2 12.3 12.4
Data Type of unit Type of Unit Type of Unit Type of Unit
Elements
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:
To calculate the monthly rate for this measure, a hospital should use one of the following options:
o Split in half (divide by 2) hours in pay periods that include 4 or more days in another month.
(See example table provided in Appendix F: 12.1 Nursing Care Hours Reporting Schedule
Example)
o Pay periods that go across two months, divide the total hours by 14 to get average daily hours,
then multiply by the number of days that belong to each month.
• Make sure ineligible staff hours are not included (e.g., unit secretary, monitor techs)
• 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.
Typical activities performed by UAPs may include (but are not limited to):
o Taking vital signs
o Bathing, feeding, or dressing patients
o Assisting patient with transfers, ambulation, or toileting
Include: Nursing assistants, orderlies, patient care technicians/assistants and graduate nurses (not yet
licensed) who have completed unit orientation
Exclude: Unit secretaries or clerks, monitor technicians, therapy assistants, student nurses who are
fulfilling educational requirements, sitters who either are not employed by the facility or who are
employed by the facility, but are not providing typical UAP activities
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.
• Eligible reporting units for this measure are defined by the allowable values for the data element, Type
of Unit.
Measure Analysis Suggestions: “None”
Terminology:
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
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
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 includes hours worked by both employees and contract staff.
Productive Hours Actual direct hours worked, not budgeted or scheduled hours. Excludes vacation, sick
time, orientation, education leave, or committee time.

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
Include:
• Nursing assistants
• Orderlies
• Patient care technicians/assistants
• Graduate nurse (not yet licensed) who have completed unit orientation
Exclude:
• Unit secretaries or clerks
• Monitor technicians
• Therapy assistants
• Student nurses who are fulfilling educational requirements
• Sitters who either are not employed by the facility or who are employed by the facility, but are
not providing typical UAP activities
Sampling: No
Age Groups: NA
Data Reported as: Aggregate rate generated from count data as a proportion.
NCS-12.1 The number of productive hours worked by RN nursing staff by type of unit as a proportion of
total productive hours worked
NCS-12.2 The number of productive hours worked by LVN/LPN staff by type of unit as a proportion of
total productive hours worked
NSC-12.3 The number of productive hours worked by UAP staff by type of unit as a proportion of total
productive hours worked
NSC-12.4 The number of productive hours worked by contract staff (RN, LVN/LPNLVN/LPN and UAP)
by unit type as a proportion of total productive hours worked
A quarterly rate may be determined by calculating a monthly rate for each unit, summing the 3 monthly rates
in a quarter and dividing by 3 to produce a quarterly average.

• ANA. National Database of Nursing Quality Indicators. (NDNQI).
• ANA. Nurse Staffing and Patient Outcomes in the Inpatient Setting. Washington,DC: American
Nurses Publishing; 1996.
• NDNQI. Guidelines for Data Collection and Submission on Quarterly Indicators, Version 5.0. Kansas
City, KS: The University of Kansas School of Nursing; January, 2005.
• Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. Nurse Staffing and Patient Outcomes
in Hospitals. HRSA Report No. 230-99-0021;February 18, 2001.

: The number of productive hours from different staff group in the calendar month
: The total number of productive hours from nursing staff in the calendar month
:
START ProdHours
Set ProdHours = 0
Missing / NSC-12b Critical Care 01

NSC-12
A
Invalid / NSC-12c Step-down 02
<= 0 NSC-12d Medical 03
NSC-12e Surgical 04
NSC-12f Med-Surg Combined 05
>0
* This refers to the data element
Missing / ‘ ’. Each case will be
NSC-12
A Invalid / stratified according to the allowable
<= 0 value for that .
>0
Missing /
NSC-12
A Invalid /
<= 0
>0
Missing /
NSC-12
A
Invalid /
<= 0
>0
Missing /
NSC-12
A
Invalid /
<= 0
>0
Missing /
NSC-12
A Invalid /
<= 0
NSC-12
A >0
Missing / Not = 01, 02, 03, 04,

Invalid 05
Missing or Invalid
Not In Measure
Measure = 01, 02, 03, 04, Population
Population Data 05
NSC-12 NSC-12 NSC-12

Z H Z

NSC-12
H
ProdHours = (RN Hours [Contract:Agency] + RN Hours [Employee] + LPN or LVN [Contract:Agency]

+ LPN or LVN [Employee] + UAP [Contract:Agency] + UAP [Employee])
Note: These RN Hours, LPN or LVN

Calculate 4 rates for the strata measure NSC – 12b: Hours, UAP Hours and ProdHours are
R1 = (RN Hours [Contract:Agency] + RN Hours [Employee]) / ProdHours belonged to strata measure NSC – 12b
R2 = (LPN or LVN [Contract:Agency] + LPN or LVN [Employee]) /
Type of Unit = 01 ProdHours
R3 = (UAP [Contract:Agency] + UAP [Employee]) / ProdHours
R4 = (RN Hours [Contract:Agency] + LPN or LVN [Contract:Agency] +
UAP [Contract:Agency]) / ProdHours
= 02, 03, 04, 05

Calculate 4 rates for the strata measure NSC – 12c:
Hours, UAP Hours and ProdHours are
R1 = (RN Hours [Contract:Agency] + RN Hours [Employee]) / ProdHours
belonged to strata measure NSC – 12c
= 03, 04, 05
Calculate 4 rates for the strata measure NSC – 12d: Hours, UAP Hours and ProdHours are
R1 = (RN Hours [Contract:Agency] + RN Hours [Employee]) / ProdHours belonged to strata measure NSC – 12d
= 04, 05
Calculate 4 rates for the strata measure NSC – 12e: Note: These RN Hours, LPN or LVN
R1 = (RN Hours [Contract:Agency] + RN Hours [Employee]) / ProdHours Hours, UAP Hours and ProdHours are
R2 = (LPN or LVN [Contract:Agency] + LPN or LVN [Employee]) / belonged to strata measure NSC – 12e

Calculate 4 rates for the strata measure NSC – 12f: Hours, UAP Hours and ProdHours are
R1 = (RN Hours [Contract:Agency] + RN Hours [Employee]) / ProdHours belonged to strata measure NSC – 12f
= 05 ProdHours
NSC-12
Z STOP

Nursing Hours
Available at:
Nursing Care Hours per Patient Day, From the Joint Commission's "Implementation Guide for the
NQF Endorsed Nursing-Sensitive Care Performance Measures", see:
Release Notes:
Version 1.00 (NSC)


Performance Measure Identifier: NSC-13

Set Measure ID# Measure Population
NSC-13.1 Hours worked by RN
nursing staff
NSC-13.2 Hours worked by nursing
staff (RN, LVN/LPN, and
UAP)
Performance Measure Name:

(NSC-13.1) Nursing care hours per patient day – Registered Nurse (RN)
(NSC-13.2) Nursing care hours per patient day - RN, Licensed Vocational Nurse
(LVN), Licensed Practical Nurse (LPN), Unlicensed Assistive Personnel
(UAP)
Description:
NSC-13.1 The number of productive hours worked by RN nursing staff per patient
day
NSC-13.2 The number of productive hours worked by nursing staff (RN, LVN, LPN,
and UAP) 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.
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:
13.1 Total number of productive hours worked by RN nursing staff with direct patient
care responsibilities by Type of Unit during the calendar month.
13.2 Total number of productive hours worked by nursing staff (RN, LVN/LPN, and
UAP) with direct patient care responsibilities by Type of Unit during the calendar month.
NSC-13.1 NSC-13.2
Included Populations Productive hours worked by RN Productive hours worked by
staff with direct patient care nursing staff (RN, LVN, LPN, and
responsibilities for greater than 50% UAP) with direct patient care
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
• Who are replaced if they the staffing matrix, and
call in sick., and • Who are replaced if they
• Work hours are charged to call in sick., and
the unit’s cost center • Work hours are charged
• Contract staff to the unit’s cost center
• Contract staff
Excluded Populations • Persons whose primary • RNs whose primary
responsibility is responsibility is
administrative in nature administrative in nature
• Specialty teams, patient • Specialty teams, patient
educators or case managers educators or case
who are not assigned to a managers who are not
specific unit. assigned to a specific
unit.
• Unit clerks, monitor
techs, and others with no
direct patient care
responsibilities
Data Elements RN Hours [Contract:Agency] LPN and LVN Hours
RN Hours [Employee] [Contract:Agency]
Month LPN and LVN Hours [Employee ]
Year RN Hours [Contract:Agency]
RN Hours [Employee]
UAP Hours [Contract:Agency]
UAP Hours [Employee]
Month
Year
Denominator Statement: Patient days by Type of Unit during the calendar month

NSC-13.1 NSC-13.2
Included Populations All patients – inpatient, short All patients – inpatient, short stay
stay patients, observation patients, observation patients and
patients and same day surgery same day surgery patients - who
patients - who receive care on receive care on an eligible
an eligible reporting unit for all reporting unit for all or part of a
or part of a day. day.
Adult medical, surgical, Adult medical, surgical, medical-
medical-surgical combined, surgical combined, critical care,
critical care, step-down units. step-down units.
Excluded Populations Other unit types (e.g., pediatric, Other unit types (e.g., pediatric,
obstetrical, rehab, etc) obstetrical, rehab, etc)
Data Elements Month Month

Patient Days Patient Days
Year Year
NSC-13.1 NSC-13.2
Data Elements Type of Unit Type of Unit
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 hours data by calendar
month.
• IF THE HOSPITAL DOES NOT HAVE MONTHLY STAFFING RECORDS:
To calculate the monthly rate for this measure, a hospital should use one of the
following options:
o Split in half (divide by 2) hours in pay periods that include 4 or more days
in another month. (See example table provided in Appendix F: 12.1
Nursing Care Hours Reporting Schedule Example)
o Pay periods that go across two months, divide the total hours by 14 to get
average daily hours, then multiply by the number of days that belong to
each month.
• 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 F: Table
3.1 Patient Day Reporting Methods) in order to calculate ratio.

• Eligible reporting units for this measure are defined by the allowable values for
the data element, Type of Unit.
Measure Analysis Suggestions: None
Terminology:
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
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
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 includes hours worked by both employees and contract staff.
Productive Hours Actual direct hours worked, not budgeted or scheduled hours.
Excludes vacation, sick time, orientation, education leave, or committee time.
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

Include:
• Nursing assistants
• Orderlies
• Patient care technicians/assistants
• Graduate nurse (not yet licensed) who have completed unit orientation
Exclude:
• Unit secretaries or clerks
• Monitor technicians
• Therapy assistants
• Student nurses who are fulfilling educational requirements
• Sitters who either are not employed by the facility or who are employed
by the facility, but are not providing typical UAP activities
Sampling: No
Age Groups: Any age patient on an eligible reporting unit is included
Data Reported as: Aggregate rate generated from count data as a ratio.
13.1 Rate of nursing care hours (RN) stratified by type of unit.
13.2 Rate of nursing care hours (RN, LVN or LPN, and UAP) stratified by type of unit.
Quarterly rate is determined by calculating a rate for each month, summing the 3
monthly rates in a quarter and dividing by 3 to produce a quarterly average.
• ANA. National Database of Nursing Quality Indicators. (NDNQI).

• ANA. Nurse Staffing and Patient Outcomes in the Inpatient Setting. Washington,
DC: American Nurses Publishing; 1996.
January, 2005.
• Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. Nurse Staffing
and Patient Outcomes in Hospitals. HRSA Report No. 230-99-0021;February 18,
2001

: The number of productive hours from different staff group in the calendar month
: The Patient Days by Type of Unit in the calendar month
:
ProdHours
START
Missing /
NSC-13 Invalid /
a1 Not = 01, 02, 03, 04,
05
= 01, 02, 03, 04,
05 NSC-13b Critical Care 01
NSC-13c Step-down 02
Missing / NSC-13d Medical 03
NSC-13
a1 Invalid / NSC-13e Surgical 04
<= 0 NSC-13f Med-Surg Combined 05
Valid
* This refers to the data element
Set ProdHours = 0 ‘ ’. Each case will be
stratified according to the allowable
value for that .
Missing /
NSC-13
c1 Invalid /
<= 0 NSC-13
I
>0
Missing /
NSC-13
c1 Invalid /
<= 0 Missing /
NSC-13
c1 Invalid /
<= 0
>0
>0
NSC-13
H Missing /
NSC-13
c1 Invalid /
<= 0
>0
NSC-13 NSC-13
a1 c1 Missing /
NSC-13
c1 Invalid /
<= 0
>0

Missing or Invalid
Measure Population Invalid /
Numerator Data
Data <= 0
>0
NSC-13 NSC-13
Z J

NSC-13
H

Hours, UAP Hours, Patient Days and
ProdHours belong to strata measure NSC
Calculate 4 rates for the strata measure NSC – 13b: – 13b
R1 = (RN Hours [Contract:Agency] + RN Hours [Employee]) / Patient
Type of Unit = 01
Days
= 02, 03, 04, 05

Calculate 4 rates for the strata measure NSC – 13c:
– 13c
Type of Unit = 02
Days
= 03, 04, 05
Calculate 4 rates for the strata measure NSC – 13d: – 13d
Type of Unit = 03
Days
= 04, 05
Calculate 4 rates for the strata measure NSC – 13e: ProdHours belong to strata measure NSC
R1 = (RN Hours [Contract:Agency] + RN Hours [Employee]) / Patient – 13e
Type of Unit = 04
Days

Calculate 4 rates for the strata measure NSC – 13f: – 13f
= 05
Days
NSC – 13
I

NSC-13
J
ProdHours = (RN Hours [Contract:Agency] + RN Hours [Employee] + LPN or LVN [Contract:Agency]

+ LPN or LVN [Employee] + UAP [Contract:Agency] + UAP [Employee])

Calculate 4 rates for the strata measure NSC – 13b: – 13b
Type of Unit = 01 R2 = ProdHours / Patient Days
= 02, 03, 04, 05

Calculate 4 rates for the strata measure NSC – 13c: – 13c
= 03, 04, 05
– 13d
Calculate 4 rates for the strata measure NSC – 13d:
= 04, 05
Calculate 4 rates for the strata measure NSC – 13e: – 13e

Calculate 4 rates for the strata measure NSC – 13f: – 13f
= 05 R2 = ProdHours / Patient Days
NSC-13
Z STOP

Appendices:
Prevalence Study Methodology
Patient Day Reporting Methods
Unit Structure Definitions
Available at:
Release Notes:
Prevalence Study
Methodology – Version 1.00
(NSC)
Appendix D
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-rate (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
Implementation Guide for the NQF D -1 Joint Commission, 2005
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.
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 is required prior to study participation. One option would be to
have an ET nurse or clinical expert organize a training session on the
National Pressure Ulcer Advisory Panel (NPUAP) staging schema.
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 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 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.
Source: California Nursing Outcomes Coalition Project Codebook, Acute Care, January
1, 2005.

Release Notes:
Methods Table – Version
1.00 (NSC)
Appendix F: Tables
Table 3.1 Patient Day Reporting Methods Table
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 Days This is an accurate method for units that have
from Actual Hours for Short Stay Patients both in-patients and short stay patients. The short
stay “days” should be reported separately from
midnight census and are added to obtain patient
days. The total daily hours for short stay patients
should be summed for the month and divided by
24.
Method 3 Midnight Census + Patient Days This method is not as accurate as using the short
from Average Hours for Short Stay Patients stay patient hours on units that have both in-
patients and short stay patients. The short stay
average is to be obtained from a special study
documenting the time spent by short stay patients
on specific unit types. Average short stay days
should be reported separately and added to the
midnight census to obtain patient days. The
average daily hours should be multiplied by the
number of days in the month and the product
divided by 24 to produce average short stay days.
Method 4 Patient Days from Actual Hours This is the most accurate method. An 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 5 Patient Days Averaged from Some facilities collect census multiple times per
Multiple Census Reports 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 multiple daily censuses
divided by the number of daily censuses can be
calculated to determine patient days for the month
on the unit.
Source: NDNQI. Guidelines for Data Collection and Submission on Quarterly Indicators,
Version 5.0. Kansas City, KS: The University of Kansas School of Nursing; January, 2005.
Implementation Guide for the NQF F-1 Joint Commission, 2005
Table 3.2 Unit Structure Definitions
Unit Name Definition - NDNQI

Critical Care- Highest level of care, includes all types of intensive care units.
adult Optional specialty designations include: Burn, Cardiothoracic,
Coronary Care, Medical, Neurology, Pulmonary, Surgical and
Trauma ICU.
Step-Down- Limited to units that provide care for adult patients requiring a lower
adult level of 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. Optional specialty designations include: Med-Surg, Medical or
Surgical Step-Down units.
Medical-adult Units that care for adult patients admitted to medical services, such as
internal medicine, family practice, or cardiology. Optional specialty
designations include: BMT, Cardiac, GI, Infectious Disease,
Neurology, Oncology, Renal or Respiratory Medical units.
Surgical-adult Units that care for adult patients admitted to surgical services, such as
general surgery, neurosurgery, or orthopedics. Optional specialty
designations include: Bariatric, Cardiothoracic, Gynecology,
Neurosurgery, Orthopedic, Plastic Surgery, Transplant or Trauma
Surgical unit
Med-Surg Units that care for adult patients admitted to either medical or
Combined-adult surgical services. Optional specialty designations include: Cardiac,
Neuro/Neurosurgery or Oncology med-Surg combined units
Source: NDNQI. Guidelines for Data Collection and Submission on Quarterly Indicators,
Version 5.0. Kansas City, KS: The University of Kansas School of Nursing; January, 2005.
Implementation Guide for the NQF F-2 Joint Commission, 2005


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Nursing-Sensitive

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

Measure Information Form

Performance Measure ID: NSC-2

Performance Measure Name: Pressure Ulcer Prevalence

Type of Measure: Outcome

Improvement Noted as: Decrease in rate

Implementation Guide for the NQF NSC 2 - 1 Joint Commission, 2005

Included Populations: Patients 18 years or older who are admitted to medical,

Risk Adjustment/Stratification: Yes

Implementation Guide for the NQF NSC 2 - 2 Joint Commission, 2005

Hospital Acquired Pressure Ulcer (Nosocomial) Nosocomial refers to new

Optional Data Elements:

Sampling: Prevalence Study Methodology

Age Groups: Age 18 years and older

Implementation Guide for the NQF NSC 2 - 4 Joint Commission, 2005

Implementation Guide for the NQF NSC 2 - 5 Joint Commission, 2005

Valid * This refers to the data element

NSC-2 Age > or = 0 days NSC-2

>= 0 and <=

NSC-2 Not = NSC-2

= 01, 02, 03, 04,

Implementation Guide for the NQF NSC 2 - 6 Joint Commission, 2005

NSC-2 Day of Hospitalization NSC-2

NSC-2 Missing / = 02, 03, NSC-2

= 01 for all ulcers

NSC-2 Missing/Invalid NSC-2

= 01 for all ulcers

NSC-2 NSC-2 NSC-2

NSC-2 NSC-2 NSC-2

Implementation Guide for the NQF NSC 2 - 7 Joint Commission, 2005

Set for the strata measure

= 02, 03, 04, 05

Set for the strata measure

Set for the strata measure

Set for the strata measure

Set for the strata measure

Implementation Guide for the NQF NSC 2 - 8 Joint Commission, 2005

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

Measure Information Form

Performance Measure ID: NSC-3

Performance Measure Name: Patient Falls

Description: All documented falls with or without injury, experienced by patients on an

Type of Measure: Outcome

Improvement Noted as: A decrease in the rate.

Included Populations: Patient falls occurring while on an eligible reporting unit.

Implementation Guide for the NQF NSC 3 - 1 Joint Commission, 2005

Risk Adjustment/Stratification: Yes

Implementation Guide for the NQF NSC 3 - 2 Joint Commission, 2005

Fall Risk Assessment A formal evaluation of a patient’s likelihood to experience

Optional Data Elements

• ANA. National Database of Nursing Quality Indicators. (NDNQI)

Implementation Guide for the NQF NSC 3 - 4 Joint Commission, 2005

NSC3b Critical Care 01

= 01, 02, 03, 04,

Missing or Invalid Missing /

Implementation Guide for the NQF NSC 3 - 5 Joint Commission, 2005

Set for the strata measure

= 02, 03, 04, 05

Set for the strata measure

Set for the strata measure

Set for the strata measure

Set for the strata measure