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EstablishING Improvement Goals

The team’s first task is to establish an aim or goal for the improvement work. By setting this goal, you will be better able to clearly communicate your objectives to all of the sectors in your organization that you might need to support or help implement the intervention.

The goal should reflect the specific aspects of CAHPS-related performance that the team is targeting. It should also be measurable and feasible. One of the limitations of an annual CAHPS survey as a measurement tool is the lag time between the implementation of changes, the impact on people’s experiences, and the assessment of that impact. For that reason, the team needs to define both ultimate goals as well as incremental objectives that can be used to gauge short-term progress. After defining your ultimate goals, ask “What is the gap between our current state and our goals?” Make of list of those gaps and use them to make SMART (specific, measurable, achievable, realistic, and time bound) incremental objectives.

For example, a team concerned about improving performance on the “Getting Timely Appointments, Care, and Information” composite measure in the Clinician & Group Survey may set a 1-year goal of a two percent increase in its composite score. At the same time, it could specify goals for the number of days it takes to get an appointment for non-urgent and urgent visits. Similarly, a team focusing on overall ratings may set goals for complaint rates for the health plan as a whole or for individual medical groups and then review those rates monthly.