Institute for Healthcare Improvement: Measures

Use a balanced set of measures for all improvement efforts:

Outcome Measures (voice of the customer or patient):
How is the system performing? What is the result?

For diabetes: Average hemoglobin A1c level for population of patients with diabetes
For access: Number of days to appointment
For critical care: Intensive Care Unit (ICU) mortality
For medication systems: Adverse drug events per 1,000 doses

Process Measures (voice of the workings of the system):
Are the parts/steps in the system performing as planned?

For diabetes: Percentage of patients with hemoglobin A1c level measured twice in the past year
For access: Average daily clinician hours available for appointments
For critical care: Use of adverse drug event chart review

Balancing Measures (looking at a system from different directions/dimensions):
Are changes designed to improve one part of the system causing new problems in other parts of the system?

For reducing time patients spend on a ventilator after surgery: Make sure reintubation rates are not increasing
For reducing patients' length of stay in the hospital: Make sure readmission rates are not increasing


	For Flow Number of patients transferred from the Emergency Department to an inpatient bed within 1 hour of the decision to admit Number of patients transferred from the Post-Anesthesia Care Unit (PACU) to an inpatient bed within 1 hour from the time patient is deemed ready to move from the PACU Number of patients transferred from the Intensive Care Unit (ICU) to an inpatient bed within 4 hours from the time the patient is deemed ready to move from the ICU Number of patients physically transferred from the inpatient facility to a long-term care facility within 24 hours after the patient is deemed ready to transfer For Access Time to third next available appointment Delay from time of appointment to time to see clinician Percentage of "good" or "very good" answers on selected patient satisfaction survey questions Average daily clinician hours available for appointments Average daily demand for appointments For Critical Care Average ICU length of stay ICU mortality rate Percent of patients/families satisfied with care Average number of days on mechanical ventilation Percent of patients with ventilator-associated pneumonia Percent of patients with catheter-induced blood stream infections For Diabetes Percentage of patients with HbA1c (blood sugar) level measured twice in the past year Percentage of patients with documented self-management goals Average HbA1c level for population of patients with diabetes Percentage of patients with documented foot exam in the past year Percentage of patients with fasting LDL cholesterol level less than 100 in the past year For Medication Systems Measures for Medication Systems

Here is how one team used sampling in measuring the time for transfer from Emergency Department (ED) to inpatient bed.

Rapid movement from the Emergency Department (ED) after a decision to admit the patient is critical flow for entry to the entire system for emergent patient care. It represents the ability of patients with various illnesses to get into the system through the most common admission route.


	Sampling approach: The measurement will consist of 6 weekly data collections of 25 patients each. The patients can be sampled in several ways: 5 patients per day for 5 days of the week. The patients must be consecutive and at least one day must be a weekend day. or 25 consecutive patients regardless of any specific day, except that it must include some weekend admissions. or If there are fewer than 25 admissions for a week, the total admissions for the week should be included in the sample. The time is measured from the decision to admit to the physical appearance of the patient into the inpatient room. The destination cannot be a "holding area" but must be a "real inpatient bed." The sample collection should be done in real time, so a data collection process needs to be worked out by members of the team to achieve this goal. The collections must be done weekly and summarized as the percentage of patients in the sample that achieved the goal for that week. Six weeks of data needs to be collected and six data points placed on a run chart.

Plotting data over time is a simple and effective way to determine whether the changes you are making are leading to improvement. Annotate the chart to show the changes you made. You can use the Improvement Tracker to automatically plot your data over time.


	Example 1: Example 2:

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