Changes in a Complex System

QI Project Measures Worksheet

When you’re trying to make a change in a complex system, you need to develop a family of measures that you will collect as data throughout the duration of your project to understand the impact of your changes. Typically, you will track 1–2 outcome measures, 3–5 process measures, and sometimes 1–2 balancing measures. Filling out a simple table with your measures can help ensure you’ve got the details you need to start.

Measure NameOperational DefinitionData Collection Plan
Provide a logical name for your measure. Most measures start with “number of,” “percent of,” or “ rate.”Define the measure in clear, specific terms. Indicate if you are using a count, a percent, “days between,” etc.If the measure is a percentage or rate, provide the numerator and the denominator.Explain how the data will be collected. Who is responsible for collecting the data?How often will the data be collected (e.g., hourly, daily, weekly)?What is to be included or excluded (e.g., include only inpatients in this measure or include inpatients and outpatients)?
Outcome measure(s):
E.g. Percent flu vaccine complianceE.g. The number of patients who receive a flu vaccine [numerator] out of the total number of people in the patient population who should receive the flu vaccine based on current guidelines [denominator].E.g. All nurses will report vaccination data into the system with each patient as usual. On a weekly basis, Nurse Susie will extract the flu vaccination data. Week over week, she will add the number of newly vaccinated patients to the previous week’s total, so that the measure is cumulative over time, and divide the current total numerator by the denominator. On Mondays, Nurse Susie will plot the recent data on a flip chart in the staff room before the weekly huddle.
Process measures:


Balancing measure(s):

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