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Research Division

Family Medicine

PDSA Cycle Step 3
Establishing Measures


Measures tell a team whether the changes they are making actually lead to improvement.
  1. Set a measurable goal for the problem solving effort by answering this question: What are we trying to accomplish?
    • The aim or performance measure should:
      • be time-specific
      • be measurable
      • define the specific population of patients that will be affected
  2. Three types of measures:
    1. Outcome measures
      • Relates to patient care
      • Examples: number of days to appointment or adverse drug events
    2. Process measures
      • The system working to provide quality of care
      • Examples: hours available to see patients, percent of patients getting screened, or Use of the Adverse Drug Events chart
    3. Balancing measures
      • Looking at changes from implemented plan and asking, are they causing problems in other parts of the system?
      • Example: Review of re-admission rates as a result of reducing patient stays in hospital.


Example Measures:

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


Go to Step 4: Testing Change/Testing the Intervention
Go to Step 5: Implementing Change
Go to Step 6: Spreading Change

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