Quality Improvement and Measurement - What Non-Executive Directors need to know

Appendix 2b - Outcome, process and balancing measures

Not every activity in a change will result in a measurable outcome, so measures are developed to show the activity has taken place. These are called process measures.

For example, if a ward agrees that three patients are to be checked every two hours against the 'SSKIN care bundle' this is recorded as a process measure (which reflects how the system is working). A bundle is simply a set of actions that, when undertaken together, have been proved to address risks. In this case, the nurse checks the Surface, observes the patient's Skin, encourages her to Keep moving, ensures she avoids Incontinence and encourages Nutrition. The outcome measure would be the absence of a pressure ulcer developing (this reflects the impact the system is having on the patient). This outcome measure could be shown at a ward or care home level as the number of 'days between' a preventable pressure ulcer developing in their patients. Other examples of outcome measures are rates of falls, or hospital acquired infection.

Balancing measures enable a system to monitor any unintended consequences (good or bad) of the improvement effort. A balancing measure in this example could be: the number of complaints received regarding pressure area care; associated costs of treating/not treating a pressure ulcer; staff satisfaction; or reduction in bed days due to 'treating' a pressure ulcer.

Balancing measures are particularly useful when there is a concern that a change might have an unintended negative consequence. An example of this was in work to improve access to psychological therapies where clinicians were concerned that the focus on access might result in poorer quality treatment. A balancing measure focused on clinical outcome data was therefore developed.