A1.4. Measuring for improvement (2)

Measuring for improvement

What should I expect the outcomes to be of using the tool?


  • You will learn if the changes you are implementing are effective.
  • Repeating STEPS 4 - 6 at intervals will demonstrate if the changes you've made are sustainable.
  • Using the 7 steps measurement process in one area could act as a precursor to applying it to another, maybe on a larger scale.

Tool/ method

Measurement for improvement:

Good measurement doesn’t happen by chance. We get it by following a 7 step process:


Why we may choose to use this tool/ method?

The data we gather helps us to make better decisions about how to improve our services. First, we collect data about our services and customers. Next, we analyse our data and turn it into a format that helps us see patterns and trends, and then review our service in the light of this intelligence.

How you might use this tool/ method?

Step 1, Decide Aim:

  • Agree with colleagues and your team what you are trying to achieve.
  • For your AIM create a statement which is SMART - simple, measurable, achievable, realistic and with clear time limits.
  • If the aim seems quite a long way from where you currently are (your baseline), break it down into smaller stages.


Step 2, Choose Measures:

With your aim firmly in mind you need to choose and develop appropriate measures.

  • Keep things simple
  • Focus on just a few at first, building these up as you become more confident


Step 3, Define Measures:

Measures nearly always require some kind of definition.

  • Specify what terms mean to ensure the definition is applied consistently and data is collected in the same way by all staff.


Be clear about

  • what data you are collecting (qualitative & quantitative)
  • where the data will come from (surveys, service users stories, manual data collection)
  • who will do the data collection & how often


Decide how to present the data so that it is helps you and others to understand what is going on

  • Quantitative data (data about numbers) is often better displayed as a bar or line graph rather than a table
  • Qualitative data (experiences, anecdotes and observations) is much more about the story itself which can be displayed by pulling key quotes from feedback, a video clip or storyboard on a wall


Step 4, Collect Data:

You will need to know how you are doing now (baseline) before you make any changes, and before you track the progress of your aim against it.

Sometimes historical data is available which you can use, but often the data you need to measure is not being collected. If this is the case, start collecting your data straight away in order to create a useful baseline.

If you want to see any improvements that are happening over time, then you need to collect enough data so that it creates a pattern or a story. You will need to collect around 25 data points. A data point is one individual piece of information. One way to ensure you get enough data points is to measure frequently.

Remember, timely monitoring allows timely intervention.


Step 5, Analyse and Present:

As part of Step 3, you have already agreed the process for presenting your data.

The process will need to be repeated depending upon how often you decided to monitor and review your measures.

You will need to update your charts regularly as you continue to collect more data.

When entering data there is also an opportunity to write on the chart. This is an extremely useful way of noting when you have made changes so that you can see if they are having any effect.


Step 6, Review Measures:

It is vital to set aside regular times with your team to look at what the data is telling you, and use this information to decide what you might need to do next. It needn’t be a long meeting – 15 – 30 minutes is adequate to review where you are and decide the next steps.

Working with your team, ask:

What outcomes did you expect?

  • Do the results indicate we are achieving those outcomes?
  • Are we confident we have arrived at the correct conclusion?
  • Do the results indicate that we should be doing something else?
  • Would any other measures tell us more?


Step 7, Repeat Steps 4-6:

Keep going. Go back to step four and repeat the “collect, analyse, review” process. Continue to collect certain data as long as it is telling you something important about how well you are doing. When measures have served their purpose – Stop.

What next?

If you have achieved your aim and successfully embedded the changes into your service you may wish to stop measuring, however

  • Even when you consistently achieve your goal over a period of time you should continue to review if further improvements could be made.
  • You could measure less frequently.
  • The process of continuing to measure (see Step 7: Repeat steps 4-6) does keep awareness high and demonstrates the importance of the goals being measured to the organisation.

Examples/ case studies/ links to best practice/ evidence



1. 7 Steps to measurement: Productive General Practice (2014). Film. NHS Institute for Innovation and Improvement. Retrieved 3 April 2014.

or http://www.youtube.com/watch?v=Za1o77jAnbw

or https://improvement.nhs.uk/resources/seven-steps-measurement-improvement/

2. The Patient Experience Book: a collection of the NHS institute for Improvement and Innovations’ guidance and support (2013). NHS Institute for Innovation and Improvement. Retrieved 15 May 2014, from http://www.cafecopywriter.com/wp-content/uploads/2017/03/The-Patient-Experience-Book-1.pdf 

3. http://www.youtube.com/watch?v=Za1o77jAnbw

4. (The How to guide for measurement for implementation) NHS Institute for Innovation and Improvement

Contact for further information



Toolkit overview
The purpose of this toolkit
What is the Cumbria Production System?
How can we transform our services?
Cumbria Production System - improvement principles
What improvement outcomes and results can we expect?
When should you use the tools?
Key tool templates and visualisations
Summary of tools
Module 1: Our approach to improvement
1.1 Plan, Do, Study, Act (PDSA)
1.2 After Action Review (AAR)
1.3 Data gathering and evidence and '5 whys'
1.4 Measuring for improvement
1.5 A3
Module 2: Seeing the issues and adding value for the people who use our services
2.1 Maximising value
2.2 Customer Journey Mapping (CJM)
2.3 Process mapping
2.4 Value Stream Mapping (VSM)
Module 3: Waste removal and standardisation
3.1 Waste, waste wheel, waste walk
3.2 Spaghetti diagrams
3.3 5S workplace organisation
Module 4: Flow, demand and standard operations
4.1 Demand analysis
Module 5: Taking people with us
5.1 Stakeholder analysis
A. The tools in detail
Module 1: Our approach to improvement
A1.1 Plan, Do, Study, Act (PDSA)
A1.2 After Action Review (AAR)
A1.3 Data gathering and evidence and '5 whys'
A1.4 Measuring for improvement
A1.5 A3
Module 2: Seeing the issues and adding value for the people who use our services
A2.1 Maximising value
A2.2 Patient/ Customer Journey Mapping
A2.3 Process mapping
A2.4 Value Stream Mapping (VSM)
Module 3: Waste removal and standardisation
A3.1 Waste, waste wheel, waste walk
A3.2 Spaghetti diagrams
A3.3 5S workplace organisation
Module 4: Flow, demand and standard operations
A4.1 Demand analysis
Module 5: Taking people with us
A5.1 Stakeholder analysis
B. Common improvement terms (glossary)
C. References and acknowledgements