Whole system measures

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The Institute for Healthcare Improvement (IHI) Whole System Measures (WSM) approach to quality improvement and coordination of quality activities provides a framework upon which future informational systems should be structured.

Far too often quality improvement activities are structured with a very limited scope and produce only a marginal effect on overall quality or outcomes. QI activities are rarely coordinated and complimentary. More often QI activities are conducted within a single, isolated department or division of a healthcare organization. In many cases the reduced scope was mandated by the information systems used. Because different departments or divisions used different IT systems, the QI project was limited to the relevant IT system.

New opportunities emerge as organizations implement enterprise wide IT systems or develop more interactive best of breed system relationships. QI activities can now be constructed across departments or divisions. Organizations now wonder how they take advantage of these new opportunities with the little resources they have available. The IHI WSM provides a useful roadmap for organizations to move forward and maximize the use of their QI resources.

Healthcare improvement

IHI used the Institute of Medicine’s 6 aims for healthcare improvement – safe, effective, efficient, timely, patient centered, and equitable – to build their 13 WSM. The 13 WSM are referenced as Big Dots up to which smaller dots (focused, limited scope QI projects). In this manner previous and ongoing QI projects can be coordinated and incorporated into an organization wide program.

The 13 measures and associated IOM Aim are:

  1. Rate of Adverse Events :# Safety
  2. Incidence of Nonfatal Occupational Injuries or Illnesses# Safety
  3. Hospital standardized Mortality Ratio (HSMR) : Effective
  4. Unadjusted Raw Mortality Percentage : Effective
  5. Functional Health Outcomes Scores : Effective
  6. Hospital Readmission Percentage : Effective
  7. Reliability of Core Measures :Effective
  8. Patient Satisfaction with Care Score : Patient-Centered
  9. Patient Experience Score :Patient-Centered
  10. Days to Third Next Available Appointment : Timely
  11. Hospital Days per Decedent During the Last 6 Months of Life# Efficient
  12. Health Care Cost per Capita :Efficient
  13. Equity (stratification of WSM) :Equitable

As health IT matures the WSM can guide the application of systems and projects to produce enterprise wide improvement. All 13 WSM are applicable to the outpatient environment while 10 are applicable to inpatient environment.

The IHI Executive Summar reads, The aim of this white paper is to describe and promote the use of a system of metrics, called the Whole System Measures, to measure the overall quality of a health system and to align improvement work across a hospital, group practice, or large health care system. The Institute for Healthcare Improvement and colleagues developed the Whole System Measures, a balanced set of system-level measures, to supply health care leaders and other stakeholders with data that enable them to evaluate their health systems’ overall performance on core dimensions of quality and value, and that also serve as inputs to strategic quality improvement planning. Properly constructed, the Whole System Measures should complement existing measures that organizations use to evaluate the performance of their heath care systems. The Whole System Measures, because they are intended to focus on important system-level measures, are limited to a small set of 13 measures that are not disease or condition-specific. One objective for developing the Whole System Measures was to also provide a view of performance that reflects care provided in different sites—both inpatient and outpatient—and across the continuum of care.

There was a time when it was mainly the providers of care who were concerned about health care quality data; this is no longer the case. Today, not only are the providers of care keenly focused on the processes and outcomes of health care delivery, but the consumers of health care—as well as managers, boards, purchasers, and policy makers—are also becoming increasingly interested in being shown that health care services are safe, effective, patient-centered, timely, efficient, and equitable. Many of the questions that drive this growing interest in health care quality measurement can only be answered with data. The WSM provide the following:

  • A useful conceptual framework for organizing measures of health care quality; and
  • A specific set of quality metrics that can contribute to a health care organization’s family of measures, balanced scorecard, or dashboard of strategic performance measures. A central premise of IHI’s work on the WSMs is that any family of measures should reflect a balance among structures, processes, and outcomes. A balanced set of system-level measures is

needed to provide leaders and other stakeholders with data that:

  • Show performance of their health care system over time;
  • Allow the organization to see how it is performing relative to its strategic plans for improvement;
  • Allow comparisons to other similar organizations; and
  • Serve as inputs to strategic quality improvement planning.

In 2003 a group of approximately 10 people from the United Kingdom, Sweden, and the United States met to discuss the idea of developing a method for measuring the quality of care at the level of a health system. They believed that although many helpful quality measures existed and more were being rapidly created, high-level measures reflecting the overall quality of a health system were largely missing. They also believed that the important work to measure hospital quality—based on an overall mortality measure called the hospital standardized mortality ratio (HSMR)—done by Sir Brian Jarman, MD, Emeritus Professor and head of the Dr Foster Unit at Imperial College in London, could serve as a model for a high-level quality measure. Together the members of this group, including leaders from IHI, believed they could develop a small set of measures to go beyond Jarman’s HSMR metric. After several months of dialogue and planning, the following health systems began to test the initial set of prototype measures the group developed:

  • Sweden: Jönköping County
  • United Kingdom: East Lancashire—Blackburn Trust, Bentley Trust
  • United States: Pursuing Perfection site7—McLeod Regional Medical Center
  • United States: IHI IMPACT network8 organizations—Geisinger Medical Center, St. John’s Mercy, ThedaCare


From the fall of 2004 through the summer of 2005, approximately 30 health systems collaborated with IHI to collect data and measure their progress using the WSMs. Lessons learned from their work and progress in the field of health care quality improvement led IHI to create a revised version of the WSMs—adding new measures where there were gaps in the system-level metrics and removing measures that were not helpful. IHI presented the WSMs to senior leaders of organizations in IHI’s IMPACT network as the proposed measurement set for their systems. Moreover, IHI’s Framework for the Leadership of Improvement calls for senior leaders and board members to focus their strategic improvement work on important measures (i.e., the “big dots”) such as mortality, harm, and patient satisfaction that reflect the quality of care delivered. Keeping in mind that the WSMs are meant to be the “big dots” at the system level, the WSMs are limited to a small set of 13 measures that are not disease- or condition-specific. One objective for developing the WSMs was to provide a view of performance that reflects care provided in different sites and across the continuum of care.

If the system is performing well at the highest level of aggregation, then it is likely to be performing well at lower levels whose measures roll up into the high-level measures. If the best possible results are not being achieved, then it is necessary to dig deeper into the causal system to identify how and where the processes of care need to be improved.

Example of Hospital Readmission Percentage

An example of a WSM is Hospital Readmission Percentage which is defined as Readmission to the hospital is a measure of both the care received in the hospital and the coordination of care back to the outpatient setting and within the outpatient setting. The Hospital Readmission Percentage is defined as the percentage of patients discharged from the hospital who are readmitted to the hospital within 30 days. Hospital Readmission Percentage = (Number of discharged patients readmitted to the hospital within 30 days of their discharge / Number of patients discharged) * 100. Exclusions:

  • Planned readmissions
  • False labor patients


Monthly [Note: There is a one-month delay in obtaining the required data due to the need to wait for 30 days post-discharge.] Method for Measuring: Each month, use your organization’s financial and/or admission information systems to identify patients who were discharged that month and also had a second admission within 30 days of the initial discharge date. Background on the Measure: This is an important measure to indicate if changes to improve patient flow through the system are negatively affecting care. While some readmissions are part of the planned care and are desirable, others may be indications of a quality issue related to a shortened length of stay and premature discharge, inadequate care, or lack of patient adherence to the care regimen following discharge from the hospital.

The Equity WSM (Stratification of Whole System Measures)

It is difficult to create a primary measure for equity. Equity is measured by stratifying the Whole System Measures, when possible, into subpopulations that differentiate by gender, age, income, or racial groupings, for example. Equity = The difference in outcome for a Whole System Measure stratified by different subpopulations. Frequency: Monthly [Note: If the sample is small and cannot be separated into subpopulations due to lack of adequate representation, monthly data should be aggregated and reviewed quarterly.] Method for Measuring: When possible, each Whole System Measure should be stratified by subpopulation. The goal is to drive the difference in outcomes between subpopulations to zero.


  1. Martin LA, Nelson EC, Lloyd RC, Nolan TW. Whole System Measures. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. Online information retrieved September 24, 2007. [1]

Submitted by Dr. Terry Olson, M.D.