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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 c contact the Canadian Patient Safety Institute Central Measurement Team at

Healthcare-Associated Pneumonia

Outcome Measure

  1. Rate of Healthcare-Associated Pneumonia per 1000 Patient Days

Process Improvement Measures

  1. Per cent Appropriate Environmental Cleaning Practice
  2. Reduction in Mean Time from Lab Notification of Positive Culture to Placement on Contact Precautions
  3. Per cent of Patients with Healthy Oral Mucosa
  4. Per cent of Staff Receiving Flu Shot
  5. Per cent of High Risk Patients Receiving Flu Shot

Ventilator-Associated Pneumonia

Outcome Measure

  1. VAP Rate per 1000 Ventilator Days

Process Improvement Measures

  1. VAP Adult Bundle Compliance
    1. Per cent of ventilated patients with the head of bed elevation to 45 degrees when possible, otherwise 30-45 degrees
    2. Per cent of ventilated patients with daily evaluation of readiness for extubation
    3. Per cent of ventilated patients with initiation of safe enteral nutrition within 24-48 hours of ICU admission
    4. Per cent of ventilated patients with the utilization of endotracheal tubes and subglottic secretion drainage (CASS)
    5. Per cent of ventilated patients with oral care decontamination with Chlorhexidine