Tackling Change

A Toolkit for Quality Process Improvement


Step 4:

Define your measures


Key Point

You can’t improve if you can’t measure the results easily and reliably!

  • You need to clearly identify what your process goals are, what your ultimate outcome goals are, and how you will measure these goals in a way that is sustainable. Consider:

    • How often will you measure?

    • At what point do we deem the project a success or failure?

    • Is gathering your measure sustainable?

  • Could this program have an effect on the bottom line of the hospital/system? Will this program affect staffing?

    • If the program will impact multiple hospitals financially, contact Hospital Financial Planning and Analysis for help in quantifying the economic impact of your change.

    • If the program will impact an individual hospital financially, please reach out to your local finance representative for assistance in quantifying and measuring financial improvement.

  • If you are tackling a patient satisfaction project, all patient satisfaction data should be coming from our standard reporting system, Cognos. If you have questions, email PatientSatHelp@upmc.edu.

  • Make sure that you are measuring both how reliably you are able to implement your change (process measures) and if your interventions have the impact you expect (outcome measures).

    • The closer to real-time data you can get, especially for process measures, the easier it will be to learn and improve.

  • Consider balancing measures — What might you negatively impact with your change?

    • For example: If length of stay goes down too much, readmissions will go up.

  • A critical strategy to understand if your changes are making a difference is to track your changes over time using a run chart. Use our easy-to-use run chart template to track and understand your data. It can be used for rates or raw numbers and can be used for process, outcome, or balancing measures.

    • See some examples of completed run charts here.

    • Refer to our power point to review the rules for interpreting run charts.

    • Need to be walked through how to use the run chart? Check out our power point.

    • Remember you must collect baseline data before you manage your change!



  • Do you need help with this step? Drop us an email at QualityQuestions@upmc.edu and Wolff Center staff will be happy to help you.

Step 4: Editable Tools

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