Validate current state
Confirm sponsorship, authority, representation, participation barriers, committee interfaces, agenda pipeline, and available measures.
Assess • decide • assign • measure • report back
Tools leaders can use immediately.
These six working tools convert PFAC evidence and Domain 5 expectations into structured decisions, ownership, measurement, and closed-loop follow-through.
Leadership workspace
Choose the decision in front of you.
Select one working tool, then focus on the domain or measure that needs attention. Full tables and downloadable templates remain available when deeper review is needed.
Tool 1
PFAC current-state assessment.
Each status shows whether supporting Dartmouth Health evidence has been reviewed for that domain. The assessment is ready to use; local conclusions remain open until the relevant evidence and operational experience are confirmed.
Inspect full working table
| Domain | Leadership question | Evidence to review | Status | Gap | Owner | Next action |
|---|---|---|---|---|---|---|
| Executive sponsorship | Is a named executive accountable for PFAC integration and follow-through? | Charter, org structure, meeting records | DH current state not yet assessed | |||
| Decision rights | Where can PFAC input influence policy, safety, design, and operations? | Charter, committee pathways, examples | DH current state not yet assessed | |||
| Advisor readiness and onboarding | Are patient and family representatives matched to defined roles and prepared for the level of participation expected? | Role-tier criteria, role expectations, confidentiality requirements, orientation, volunteer requirements, role matching, representative database, monitoring process | DH onboarding process documented; implementation across locations not validated by this APE | Need site-level confirmation of adoption, consistency, advisor experience, and connection to PFAC governance | Use the documented onboarding process as an existing asset, then validate how it operates in practice | |
| Agenda pipeline | Do departments bring substantive initiatives to the PFAC before decisions are final? | Agendas, project intake, meeting minutes | DH current state not yet assessed | |||
| Measurement | Are PFAC contributions and resulting actions measured? | Trackers, dashboards, project measures | DH current state not yet assessed | |||
| Report-back | Do patients and families learn what changed, what did not, and why? | Minutes, communications, action logs | DH current state not yet assessed |
A Dartmouth Health Office of Care Experience onboarding job aid approved March 3, 2026 documents three participation tiers and a six-step process from expression of interest through ongoing monitoring. It is evidence of an existing onboarding structure, not proof that every location implements the process consistently or that PFAC decision authority, representation, and outcomes are established.
Download CSV template · Open governance charter starter · Review launch charter
Tool 2
Closed-loop action tracker.
Move a patient or family signal from discussion to disposition, ownership, evidence of change, and report-back.
Inspect full working table
| Date | Patient/family signal | Source | Leadership disposition | Owner | Due date | Status | Evidence of change | Report-back completed |
|---|---|---|---|---|---|---|---|---|
| PFAC | Open | No |
Tool 3
Representation and access check.
Check whether the voices around the table reflect the population served and whether participation barriers are being actively addressed.
Inspect full working table
| Dimension | Current representation | Who may be missing | Participation barrier | Mitigation | Evidence source | Review date |
|---|---|---|---|---|---|---|
| Geography / rurality | Travel, time, broadband | |||||
| Language | Interpretation, translated materials | |||||
| Disability access | Physical, sensory, cognitive, digital access | |||||
| Socioeconomic access | Compensation, childcare, work schedule | |||||
| Care setting / condition | Recruitment channel, specialty concentration |
Tool 4
Measurement plan.
The measurement design reflects the APE's structure, process, and outcome framing while adding implementation measures to show whether patient and family input entered accountable work. Depending on the workstream, leaders may interpret PFAC contribution alongside PREMs, PROMs, Press Ganey measures, access measures, safety signals, complaints, or other project-specific data already used to understand the problem.
Inspect full working table
| Measure level | Example question | Metric | Data source | Frequency | Owner | Interpretation caution |
|---|---|---|---|---|---|---|
| Structure | Is the PFAC connected to leadership and governance? | Named sponsor, charter, committee links | Governance records | Annual | Presence does not establish effectiveness. | |
| Process | Is substantive work reaching the PFAC? | Agenda utilization, departments presenting | Agendas | Quarterly | Volume does not establish influence. | |
| Implementation | Does input lead to documented action? | Recommendation adoption, action closure | Action tracker | Quarterly | Association does not establish downstream clinical effect. | |
| Experience | Do patients/families perceive responsive engagement? | Selected experience signals | PREMs, Press Ganey, complaints, or other experience data as appropriate | Defined locally | Do not attribute system-level change to PFAC alone. | |
| Outcome | Did a targeted project improve its intended result? | Project-specific outcome | PROMs, operational, clinical, access, safety, or other workstream-specific data | Project-specific | Use an appropriate evaluation design before causal attribution. |
Tool 5
Domain 5 traceability.
Each status shows whether Dartmouth Health evidence supports the corresponding Domain 5 element. The tool is ready to use; local conclusions remain open until the relevant evidence is reviewed and confirmed.
Inspect full working table
| Requirement / guidance element | Local evidence | Evidence status | Gap | Accountable role | Action | Validation source |
|---|---|---|---|---|---|---|
| Patient and family engagement structure | DH evidence not yet assessed | AHRQ/CMS source | ||||
| Patient/family input into safety | DH evidence not yet assessed | AHRQ/CMS source | ||||
| Leadership accountability and follow-through | DH evidence not yet assessed | Local governance evidence |
Tool 6
90-day PFAC operating plan.
Sequence the first implementation cycle so leaders validate the current state, launch one bounded workstream, assign ownership, define measures, and close the first report-back loop before expanding scope.
Run one workstream
Bring one substantive problem to the PFAC before final decisions, document recommendations and disposition, and assign owners and due dates.
Close the learning loop
Review implementation evidence, unresolved barriers, project signals, and report-back completion, then decide what to adapt or expand.
Download 90-day operating plan · Open executive launch brief