Using Measures to Monitor Progress in Improving Patient Experience

When a team establishes its goal, it typically specifies one or more performance metrics to assess whether a change leads to improvements in patient experience. These measures should be clearly linked to both the larger goal and the intervention itself. For example, if the goal is to speed specialist referrals, you could measure the time it takes to get a response from the specialist's office or an approval from the health plan.

Selecting Measures

Choose measures that allow you to track each of the three steps in the improvement process of Do, Study, and Act. Measures should be able to:

• Test the acceptance of and/or adherence to new or revised practices.
• Examine how and how much the new practices are affecting the delivery of patient-centered care.
• Assess how much patient experience of care is improving.
• Detect possible unintended consequences.

Seek a feasible number of measures that address the most important aspects of the improvements you are trying to achieve. Too many measures could create a burden on the staff, leading to loss of attention due to information overload; too few measures may omit tracking of important aspects of the changes you are making.

Communicate with the full array of stakeholders and staff about why the measures are being collected and how these data will help improve their quality of work life and patient experience.

Displaying Data

It is important to visualize and monitor performance on the selected measures.

• Control or run charts are helpful tools for regularly assessing the impact of process improvement and redesign efforts. Data can be reported monthly, weekly, or even daily. A run chart can show the various data collection points plotted over time in one visual for a specific survey question. By tracking the responses to a given question at regular and frequent time intervals, managers can discern how process improvement interventions relate to changes in survey results. If an intervention appears to have positive results, it can be continued and sustained; if not, it can be modified or discontinued.
• Dashboard reports present important data in summary form to make it easier to identify gaps in performance and trend performance against goals. Dashboards can be a useful method for sharing consistent information across multiple levels of an organization. For example, the Massachusetts General Physicians Organization (MGPO) prepares quarterly leadership dashboards with benchmarks and targets, where relevant, at a summary level across clinical services, at the clinical service level, and at the practice level.²

Learn more about using measures:

• Institute for Healthcare Improvement. Model for Improvement: Establishing Measures.
• Carey RG, Lloyd RC. Measuring Quality Improvement in Healthcare: A Guide to Statistical Process Control Applications. New York: American Society for Quality; 1995.
• Jazieh AR. Quality Measures: Types, Selection, and Application in Health Care Quality Improvement Projects. Glob J Qual Saf Healthc 2020 Nov 30;3(4):144-146. doi: 10.36401/JQSH-20-X6. PMID: 37260572; PMCID: PMC10229016.
• Pavol Gejdoš. Continuous Quality Improvement by Statistical Process Control. Procedia Economics and Finance 2015; 34: 565-572. https://doi.org/10.1016/S2212-5671(15)01669-X.
• Thor J, Lundberg J, Ask J, Olsson J, Carli C, Härenstam KP, Brommels M. Application of statistical process control in healthcare improvement: systematic review. Qual Saf Health Care 2007 Oct;16(5):387-99. doi: 10.1136/qshc.2006.022194. PMID: 17913782; PMCID: PMC2464970.
• Wheeler D. Understanding Variation: Keys to Managing Chaos. Knoxville, TN: Statistical Process Controls, Inc.; 1993.

^1. Agency for Healthcare Research and Quality. How Two Provider Groups Are Using the CAHPS® Clinician & Group Survey for Quality Improvement. CAHPS Issue Brief. Available at: https://ahrq.gov/cahps/quality-improvement/reports-and-case-studies/cgcahps-webcast-brief-2014.pdf (3.4 MB). Accessed on March 24, 2025.