NSQI Update


1, Issue 2: February 6, 2009

  • Eighty Washington hospitals participate in NSQI
  • Questions been raised from users
  • The new pressure ulcer incidence indicator
  • Jane Feldman returns to the NSQI Project
  • Announcement of a users' group web cast
  • Archives of project information

Eighty Washington Hospitals Participate in NSQI

Eighty Washington Hospitals Participate in NSQI
Thanks to all of you participating in this project -we have passed the 80 hospital mark! 

Some hospitals are already entering data into the Quality Benchmarking System (QBS) platform, while most are still in the preliminary data collection phase.  Please let us know how we can help you move through this process and begin actively up-loading data.  Contact information is included in the section entitled "Jane Feldman returns to the NSQI project" (below).

Questions Raised by Users

  • We do not qualify for all of the definitions, what can we do?  For those of you in this situation, we suggest working with your nurse staffing committee to identify and develop alternate measures that fit your organization. 
  • How is NSQI going to aggregate this information data or present comparative data?  We would like your ideas on how to aggregate your hospital's performance and compare it with either the average of the group or with the "best" score.  This is difficult due to the variability in how some data is defined (especially staffing numbers) and in unit definitions.  We will be exploring the development of meaningful "peer" groupings over time.  One option might be to develop two or three cuts based upon hospital size.  If you have other ideas please send them to us.

The New Optional Pressure Ulcer Incidence Indicator is Available
The definition of the pressure ulcer incidence indicator discussed in the last issue has been approved and is being loaded into the QBS reporting system.  It should be available by late next week on the QBS platform.  You can chose either indicator or use them both.  Remember that if you switch back and forth, you will not have any information that can be trended.

The indicator is included at the end of this Update and will be posted in the archive file.

Jane Feldman Returns to the NSQI Project 
We are pleased to announce that Jane Feldman is re-joining the NSQI project staff.  Her primary focus will be the technical components of data reporting and, later, aggregation and comparison.   Jane can be reached at or (206) 216-2505.

Jim Cannon will continue as the primary project lead as mentioned in the last edition.  You are welcome to address any questions to either Jane or Jim at (206) 216-2551 or

A Users' Group Web Cast Will be Held February 20
A web cast for users is scheduled on February 20, 2009 from noon to 1:00 p.m.  The intended audience is you and others with an interest in the project.  The primary purpose of this session is to answer issues with data collection, reporting and use of the Quality Benchmarking System platform.  An announcement with connection information will be sent to you in about a week.

Archives of Project Information 
We are posting the NSQI Update and other pertinent project information on the WSHA website at page is located on the WSHA website under the current projects tab.


Performance Measure Name:  Pressure Ulcer Incidence

Description:  The number of Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility by unit.

Source:  National Quality Forum, Care Management Events

Rationale:  While the NSQI "pressure ulcer prevalence" measure has been adopted as nurse sensitive, many hospitals found it burdensome for quick adoption.  This alternate was selected as being very similar to the required reporting to the Washington State Department of Health and, therefore, not requiring more data collection.  Participating hospitals may choose either indicator or both.

Numerator Statement:  Patients identified as having acquired a Stage 3 or 4 pressure ulcer after admission to a facility.
    Excluded populations:

  • Patients who progress from Stage 2 to Stage 3, if Stage 2 was recognized upon admission.
  • Patients with skin breakdown due to arterial occlusion, venous insufficiency, diabetes related neuropathy, or incontinence dermatitis.

Denominator Statement:  Total patient days for the selected unit for the month reported.

    Included populations:  Patients 18 years or older who are admitted to medical, surgical.  Medical-surgical combined critical care, and step-down units.

    Excluded populations:  Patients less than 18 years of age.

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