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​Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures).

Below are some recommended measures to use, as appropriate, to track your progress. In selecting your measures, consider the following:

  • Whenever possible, use measures you are already collecting for other programs.
  • Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.
  • Try to include both process and outcome measures in your measurement scheme.
  • You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.
  • Posting your measure results within your hospital is a great way to keep your teams motivated and aware of progress. Try to include measures that your team will find meaningful and exciting (IHI, 2011).

For more information on measuring for improvement, contact the Canadian Patient Safety Institute Central Measurement Team at measurement@cpsi-icsp.ca

Outcome Measure

(Safer Healthcare Now! 2015)

  1. Percentage of Clean and Clean Contaminated Surgical Patients with Surgical Infection (Safer Healthcare Now! 2014)
  2. Percentage of Surgical Procedures with Surgical Infection
  3. Central Line-Associated Primary Bloodstream Infection (BSI) Rate per 1,000 Central-Line Days (Safer Healthcare Now! 2012)
  4. Incidence of HAI-MRSA Clinical Isolates per 1000 Patient Days (Safer Healthcare Now! 2010)
  5. Incidence of HAI-VRE Clinical Isolates per 1000 Patient Days (Safer Healthcare Now!, 2010)
  6. Incidence of HAI-CRE Clinical Isolates per 1000 Patient Days
  7. Incidence of HAI-CDAD Positive Toxin Assay per 1000 Patient Days (Safer Healthcare Now! 2010)

Process Improvement Measures for Surgical Site Infections

(Safer Healthcare Now! 2014)

  1. Percentage of Clean and Clean-Contaminated Patients with Timely Prophylactic Antibiotic Administration
  2. Percentage of Clean and Clean-Contaminated Patients with Appropriate Prophylactic Antibiotic Discontinuation
  3. Percentage of Surgical Patients with Appropriate Hair Removal
  4. Percentage of All Diabetic or Surgical Patients at Risk of High Blood Glucose with Controlled Post-Operative Serum Glucose Post Op Day 0, 1, and 2
  5. Percentage of All Clean or Clean-Contaminated Surgical Patients with Normothermia within 15 Minutes prior to Skin Closure or on Arrival in Post Anaesthetic Care Unit
  6. Percentage of Clean and Clean-Contaminated Patients with Pre-Op Wash With Soap or Antiseptic Agent
  7. Percentage of Clean and Clean-Contaminated Surgical Patients with Appropriate Intra-Op Skin Cleansing on Intact Skin
  8. Percentage of Clean and Clean-Contaminated Patients Receiving 2 grams of Cefazolin as Prophylactic Antibiotic
  9. Percentage of Clean and Clean-Contaminated Surgical Patients Receiving Appropriate Prophylactic Antibiotic Redosing
  10. Percentage of Clean and Clean Contaminated Surgical Patients with Evidence of Surgical Site Infection at or Prior to Discharge
  11. Percentage of Clean and Clean Contaminated Surgical with Appropriate Selection of Prophylactic Antibiotics (Optional)

Process Improvement Measures for Central Line Associated Bloodstream Infections

(Safer Healthcare Now! 2012)

  1. Central Line Insertion Bundle Compliance:
    1. Hand hygiene
    2. Maximal barrier precautions
    3. Chlorhexidine skin antisepsis
    4. Optimal catheter type and site selection
  2. Central Line Maintenance Bundle Compliance:
    1. Daily review necessity for line with prompt removal of unnecessary lines
    2. Accessing the lumens aseptically
    3. Catheter site and tubing care

Process Improvement Measures for Hand Hygiene

(Safer Healthcare Now! 2010)

  1. Percentage of Appropriate Hand Hygiene Practice

Process Improvement Measures for Wound Care

(Orsted et al., 2010)

  1. Percentage of Patients Undergoing a Surgical Wound Healing Risk Assessment
  2. Percentage of Patients Who Had An Individualized Treatment Plan to Eliminate and Reduce Risk Factors
  3. Percentage of Patients/Family/Caregivers Who Received Surgical Wound Healing Education
  4. Percentage of Patients Who Had Surgical Wound Assessment and Documentation Starting 48 Hours Post-Op
  5. Percentage of Patients with Appropriate Dressing for the Acute Phase of Surgical Wound Healing