Aims and Measures
Creating an Aim
An aim statement is written documentation of what you hope to achieve from your quality improvement project. Your aim should be specific, define the scope of your project, include clear measurable targets and address an issue that is important to everyone involved. The population or system that will be affected should also be defined. Remember to link your aim to the benefits it will bring. This should all be encapsulated into a succinct statement that is easy for others to understand whilst avoiding extraneous information.
When this is completed, reflect on whether your aim statement is SMART.
An example statement might be “Improve patient outcomes by reducing post-operative hospital acquired pneumonia rates by 5% over one year on the general surgical wards”.
First identify the process you wish to improve and then involve the stakeholders! This involves forming an interprofessional team with people that represent all of the processes due to be affected by the improvement project. It should include those with authority, those with technical expertise and those who will drive the project on a day-to-day basis. Develop the aim together as this builds a shared sense of involvement. Remember to make sure it follows the SMART criteria. Don’t worry if you need to refocus the aim in the future; this is very common and it is a good way to redefine the project as more information comes to light.
You will find that more complex projects will often benefit from multiple aims. In fact, with large projects it is possible to nest aim statements. You can produce short-term aims and use these as incremental goals as part of a longer-term aim. This has the benefit of identifying different areas for improvement, as well as allowing separation of aims dependent upon the level at which members of the group work within the organisation.
Read more from NHS Improvement on how to develop your aim.
Choosing a Measure
Measures are used to understand if your intervention has had an effect and determine whether this change is positive or negative. The resultant data you collect helps in several ways. It can be used to understand your current performance (baseline), come up with improvement ideas, test changes to see if they lead to improvement and ensure the improvements are being maintained. Measures may be both qualitative and quantitative. For ease, ensure your measures involve data that someone is already collecting or is easy to collect.
In an ideal world, the introduction of change would occur within a scientifically controlled environment where only one change would be tested at a time. The reality is rather different with a complex world that is full of moving parts. Recognising that the creation of a controlled environment is impossible, we can compromise and make small adjustments while observing for their effects over time. Utilising this approach means that one measure will not enable us to understand the full impact of our change. Instead, we must employ a family of measures to get the best chance of understanding the full effects. A final word of caution; bias is inevitable within the complex world. We cannot eliminate bias, but we can control for it by trying to keep everything else, including the bias, consistent.
A Family of Measures
There are three types of measure that you should use within your quality improvement project. Each has a unique role and provides a different perspective from which to monitor your project. You should aim to use 1x Outcome Measure, 2-4x Process Measures and 1-2x Balancing Measures. These are defined below:
The measure you want to change. It reflects the end result of your improvement and shows how the system is performing. This could be an absolute number, percentage or rate of change.
These measures explore the way the system is performing to deliver the outcome you want. They help you understand if the system is working as planned.
These measures reflect what might be happening elsewhere in the system as a result of the intervention. They assess whether the intervention is inadvertently introducing undesirable problems elsewhere.
Balancing measures are not always necessary. However, think carefully if you choose not to use them. They may protect you from making the assumption that observed changes were the result of your intervention when they may have been due to something you hadn’t been observing.
Read more from NHS Improvement on using a family of measures.
Measures should be clearly defined and specific to the purpose for which they were chosen. They should be created in a similar way to the aim statement. Clearly state why you have chosen this measure and how you have arrived at it. Use as much detail as you can to define each term used within the measure. For example, if measuring ‘the number of timely discharges’, ensure you define what ‘timely’ means and what is included within the term ‘discharge’. Make sure the definitions you use are repeatable and reproducible. It is also good practice to spare a moment and consider how you will display these measures in your results. To avoid unnecessary data collection, answer the following questions while creating your clearly defined measure.
- What do you want to learn about and improve?
- What measures will be most helpful for this purpose?
- Is it a project level measure? These monitor progress towards an overall goal.
- Is it a PDSA level measure? These monitor results of specific tests of change.
- What is the operational definition of each measure?
- Define the measure in unambiguous terms.
- Define the characteristics used to describe the measure. For example, what is your definition of accurate or timely?
- How are the scores that you use derived?
- Which patient groups will be affected?
- What is the baseline?
- Collect data related to both the numerator and denominator.
- What is the goal?
- Is it created internally or is it being forced by an external team?
- When will it be achieved by?
Read more from NHS Improvement on the seven steps they use to measure for improvement.
Example Aim and Measures
Aim Statement: Decrease the average BMI of the population requiring CPAP for Obstructive Sleep Apnoea from 35 to 30kg/m^2 within 18 months.
Outcome Measure: The BMI of patients using CPAP for Obstructive Sleep Apnoea.
Process Measure: The percentage of patients using CPAP for Obstructive Sleep Apnoea whose BMI was measured twice within the last 18 months.
Balancing Measure: The number of patients lost to follow up.