What DH already has
Visible inventory of patient and family engagement structures, including PFAC-related work, ConnectShareCare, learning collaboratives, patient story resources, and documented advisor onboarding processes.
DH value-add • benchmark framework • evidence status
Evaluate where Dartmouth Health is strong, where evidence is still needed, and where the toolkit can add value.
This page is a benchmark assessment framework, not a finished rating. It identifies the evidence needed to assess PFAC governance, PSSM 5 alignment, patient and care partner engagement, measurement, equity, and learning health system practice.
Honest status
This is not a scored evaluation of Dartmouth Health.
The framework is real as a structured assessment method. It is not yet real as a scored benchmark based on complete Dartmouth Health data.
Some local operating processes are now documented, including role-tiered onboarding for Patient and Family Representatives. That is evidence of an existing asset, but it does not establish systemwide implementation, PFAC authority, representativeness, closed-loop measurement, or outcomes. Scoring should occur only after reviewing public materials, project documents, stakeholder input, and available performance data.
Evidence-backed preliminary findings
What is supported, what is not yet validated, and where evidence is still insufficient.
| Status | Item | Current finding | Limitations and next evidence needed |
|---|---|---|---|
| Publicly supported | ConnectShareCare | Public sources support that Dartmouth Health has sponsored a patient and care partner engagement asset. | This does not prove PFAC governance authority, systemwide reach, or measurable improvement. Review charters, reporting paths, and action logs next. |
| Publicly supported | Promise Partnership Coproduction Learning Health System | Public pages and a peer-reviewed case study support the coproduction learning health system context. | This does not show how every PFAC recommendation moves into leadership decisions. Map the connection from engagement activity to operating decisions. |
| Preliminary finding | Care Experience Collaborative | Public information suggests an improvement structure that may be relevant to patient and family engagement. | The available public source does not yet prove PFAC membership, cadence, decision rights, or closed-loop reporting. |
| Project document reviewed | Patient and Family Representative onboarding | A Dartmouth Health Office of Care Experience job aid approved March 3, 2026 documents three participation tiers, onboarding responsibility, role expectations, confidentiality and orientation requirements, role matching, representative database entry, and ongoing monitoring. | The document establishes a defined onboarding process, not evidence that every Dartmouth Health location implements it consistently or that PFAC governance authority, representation, closed-loop action, or outcomes are established. Validate site-level use and advisor experience next. |
| Not yet validated | DH PFAC governance authority | Governance authority cannot be assessed from the evidence reviewed so far. | Collect or review charters, agendas, sponsorship model, decision logs, and escalation pathways. |
| Not yet validated | Measurement and feedback loop | Closed-loop measurement cannot be assessed from the evidence reviewed so far. | Collect or review dashboards, closed-loop reports, action trackers, and before-and-after summaries. |
| Insufficient evidence | Equity and representation | Current evidence is not enough to assess whether engagement reflects the communities served. | Review recruitment approach, language access, rural access, caregiver diversity, disability access, and participation barriers. |
Reusable evidence table
Each future benchmark claim should use the same fields before any score is considered.
| Domain | Evidence item | Evidence type | Source title | Source URL | Date reviewed | Current finding | Limitation | Confidence | Gap | Recommended action | Public safe | Include on site |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Engagement infrastructure | ConnectShareCare public story page | Public web source | ConnectShareCare story page | Public source | September 7, 2026 | Dartmouth Health-supported engagement asset is publicly visible. | Does not prove governance authority or outcomes. | Moderate | Need operating owner, reporting path, and use in improvement decisions. | Use as one input in the engagement infrastructure asset map. | Yes | Yes |
| Learning health system connection | Promise Partnership public pages and case study | Public web source and peer-reviewed article | Promise Partnership Coproduction Learning Health System | Public source | September 7, 2026 | Public sources support a coproduction learning health system context. | Does not prove closed-loop PFAC action for the benchmark domains. | Moderate | Need evidence of specific patient-family input moving into decisions. | Map where PFAC, patient story, collaborative, and measurement workflows intersect. | Yes | Yes |
| Measurement and feedback | Care Experience Collaborative public description | Public web source | Promise Partnership learning collaboratives | Public source | September 7, 2026 | Public source suggests a possible improvement structure for experience work. | Does not document PFAC authority, membership, metrics, or report-back practice. | Low | Need agendas, owners, measures, and closed-loop examples. | Treat as a preliminary finding and validate before using it as scoring evidence. | Yes | Yes |
| Advisor onboarding | Role-tiered onboarding process | Dartmouth Health project document | Onboarding Patient and Family Representatives by Role—Tiered Process/Requirements | September 8, 2026 | The Office of Care Experience job aid documents three participation tiers and a six-step onboarding process from expression of interest through ongoing monitoring. | Documented process does not establish consistent implementation across locations, advisor experience, governance authority, representativeness, or outcomes. | Moderate | Need site-level implementation evidence and connection to PFAC governance and decision pathways. | Use as a documented current-state asset and validate operation in practice. | Yes, summary only | Yes | |
| PFAC authority | PFAC charter, agendas, decision logs, and escalation path | Project document or internal artifact | Not reviewed | Not yet scored. | No reviewed evidence yet. | Insufficient | Need source documents and stakeholder confirmation. | Collect the governance evidence before making any public claim beyond the framework question. | No | No | ||
| Equity and representation | Recruitment, access, and representation evidence | Stakeholder input, metric, or internal artifact | Not reviewed | Not yet scored. | Public evidence is not enough to assess representativeness. | Insufficient | Need language access, rural access, caregiver diversity, age, disability, and participation-barrier evidence. | Add equity fields to the benchmark intake before publishing findings. | No | No |
Benchmark assessment framework
Domains for evidence collection before scoring.
| Domain | Assessment question | Evidence to collect | APE value-add |
|---|---|---|---|
| Engagement infrastructure | What formal and informal structures capture patient and care partner voice? | PFACs, ConnectShareCare, story programs, collaboratives, support groups, advisory roles, onboarding processes. | Map existing assets into one usable engagement ecosystem. |
| PFAC authority | Does patient and family input reach people who can change policy, workflow, environment, safety practice, or communication? | Charters, agenda pathways, executive sponsorship, decision logs, escalation processes. | Define the governance bridge from PFAC voice to leadership action. |
| PSSM 5 alignment | Does the system have a clear structure for patient and family engagement, including PFAC input on safety? | PSSM 5 documentation, safety committee connections, meeting evidence, patient safety topics. | Create traceability between PFAC practice and PSSM 5 readiness. |
| Learning health system connection | Does patient voice feed into learning, redesign, measurement, and improvement? | Closed-loop reports, project charters, change logs, learning collaborative outputs. | Turn listening into a repeatable evidence-to-action workflow. |
| Measurement and feedback | Can DH show what was heard, what changed, who owned the fix, and whether the change improved experience or safety? | Metric dashboards, CAHPS/Press Ganey measures, action owners, before-and-after summaries. | Connect PFAC work to meaningful patient experience and safety signals. |
| Equity and representation | Are patient and family voices representative of the communities served? | Recruitment strategy, language access, rural access, age, disability, digital access, caregiver diversity. | Make representation a design requirement, not an afterthought. |
| Spread and sustainability | Can engagement practices scale across hospitals, ambulatory sites, service lines, and collaboratives? | Reusable templates, training, onboarding, operating cadence, leadership reporting. | Package the method as a toolkit that can be reused across DH settings. |
Evidence needed before scoring
The next pass turns the framework into a data-backed benchmark.
| Domain | Current finding | Confidence | Gap | Recommended action |
|---|---|---|---|---|
| Engagement infrastructure | Public evidence exists for ConnectShareCare and Promise Partnership, and a reviewed Dartmouth Health project document establishes a defined Patient and Family Representative onboarding process. | Moderate | Full inventory and site-level validation of PFAC-related structures still needed. | Build an asset map from public sources and available project documents, then validate operation with local stakeholders. |
| PFAC authority | Not yet scored. | Insufficient evidence | Need proof of governance path from patient input to decision-making. | Request or identify charters, agenda flow, sponsors, action logs, and reporting cadence. |
| PSSM 5 alignment | Not yet scored. | Insufficient evidence | Need documentation connecting PFAC input to patient safety structures. | Map current engagement work against AHRQ PSSM 5 language and safety committee touchpoints. |
| Measurement and feedback | Not yet scored. | Insufficient evidence | Need closed-loop evidence showing what changed after patient and family input. | Create a source-to-action tracker with owner, date, metric, status, and report-back method. |
| Equity and representation | Not yet scored. | Insufficient evidence | Need recruitment and access evidence for representative participation. | Add equity and access fields to PFAC recruitment, agenda review, and collaboration intake. |
Benchmark outputs
What the APE should produce for Dartmouth Health.
Where the loop is weak
Identification of places where patient voice is collected but not yet clearly connected to leadership action, safety review, measurement, or system redesign.
What DH can do next
A practical set of recommended actions for governance, measurement, representation, closed-loop reporting, and toolkit adoption.
Continuous improvement question
Can DH prove that patient voice changed the system?
The benchmark should help DH move beyond whether engagement activities exist. The stronger question is whether patient and family voice changes decisions, improves experience, prevents harm, strengthens trust, and teaches the system how to improve.
What was heard?
What changed?
Who owned the change?
What improved?
How was the result shared back?