How to Establish Performance Baselines for Your Healthcare Team

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Endeavor for Excellence: Step 4 – Establish Performance Baselines

If you have been following along for the redeployment of MedicalGPS’ service improvement program, this week we move into Step #4 — establishing baseline performance measures.  

If you have not been following along but have been looking for a proven, field-tested service improvement process to enhance customer service levels at your practice, feel free to click the links below to get started.    If you have already reviewed E4E steps #1, #2, and #3, skip over the 10-steps listed below and pick up with step #4 below, titled, “How to Establish Baseline Performance Measures”.

clinic, profession, people and medicine concept - happy female doctor with tablet pc computer over group of medics meeting at hospitalEndeavor for Excellence:  10 Steps to Improved Customer Service

Step 1: Review E4E 10 Steps and Consider if E4E Might be Right for Your Practice

Step 2: Identify and Select Members for Your E4E Team

Step 3: Complete the E4E “Before” Best Practices Checklist (Checklist coming soon)

Step 4: Establish Performance Baselines (Utilize patient experience survey data or contact MedicalGPS to obtain a version of M3-Patient Experience®)

Step 5: Administer Customer Service Training (MedicalGPS YouTube Video coming soon)

Step 6: Conduct Quality Assurance Observations (QC Checklist coming soon)

Step 7: Review and Administer “Messaging: What, When, and Why” Training (MedicalGPS YouTube Video coming soon)

Step 8: Administer “Scheduling: Protocols, Patient Flow, and Exceeding Patient Expectations” Training, (MedicalGPS YouTube Video coming soon)

Step 9: Administer, “Sustaining Effective Implementation and Measuring Success”, (MedicalGPS YouTube Video coming soon)

Step 10: Review Patient Experience Performance Trends and Compare to Baselines, (MedicalGPS YouTube Video coming soon)

Happy doctor female wearing coat attending to her patient in a consultation while is holding a medical history sitting in a desktopHow to Establish Baseline Performance Measures

Listed below are seven steps for establishing baseline measures.  Review the list.  If your organization has an ongoing patient experience survey in place, such as M3-Patient Experience®, many of the seven steps have already been accomplished for your practice.  If that is the case, great!  If not, read on for more details regarding each of the seven steps.

  1. Collect Patient Experience Survey Data
  2. Determine Key Performance Indicators (KPIs)
  3. Ensure Adequate Sample Sizes
  4. Collect Additional Data (if needed)
  5. Analyze Performance Trends (Averages, Maximum Values, Minimum Values, Percentiles) 
  6. Set Performance Targets and Goals
  7. Measure, Monitor, and Modify

Below are some additional details.  After you have reviewed the details, if you have questions or need assistance, the members of the MedicalGPS team would be honored to assist you.  Feel free to click here to reach any one of us, or, you are more than welcomed to email me directly at

Now, some insights related to establishing your performance baseline and setting targeted goals.

m3-patient experience measuring charts

1 – Collect Patient Experience Survey Data

There are many ways (modes) to collect patient experience survey data.  There are pros and cons to every survey mode (paper, telephone, internet, etc.).  Having been in the patient experience survey business since 1995, it has been MedicalGPS’ experience that the most affordable and effective mode of data collection is via the internet.  Having an ongoing patient feedback process that is real-time, or near real-time, allows for continuous service improvement.

Chances are that your practice already has some sort of a patient satisfaction/experience survey in place.  If not, there is no need to reinvent the wheel and attempt to start from scratch.  Contact MedicalGPS and we’ll be glad to get you started.  If you already have a process in place – perfect.

Sample Questions

2 – Determine Key Performance Indicators (KPIs)

Using your patient satisfaction/experience survey questionnaire, select the questions that measure the areas that you and your team have decided to work towards improving.  For example, the four areas listed below, and corresponding questions, are the KPIs and focus questions as selected by one of MedicalGPS’ clients.  Click here to review and download a sample questionnaire.

Receptionist Helpful:

In the last 6 months, how often are the clerks and receptionists at this provider’s office as helpful as you thought they should be?

  • Always
  • Usually
  • Sometimes
  • Never

Acute Access:  

In the last 6 months, when you contacted this provider’s office to get an appointment for care you need right away, how often do you get an appointment as soon as you needed?

  • Always
  • Usually
  • Sometimes
  • Never
  • I have not contacted the provider’s office under this circumstance in the last 6 months

Same Day Call Backs:

In the last 6 months, when you contacted this provider’s office during regular office hours, how often do you get an answer to your medical question that same day?

  • Always
  • Usually
  • Sometimes
  • Never
  • I have not contacted the provider’s office with a medical question in the last 6 months

Provider Rating:

Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

  • 10 best provider
  • 9
  • 8
  • 7
  • 6
  • 5
  • 4
  • 3
  • 2
  • 1
  • 0 worst provider
  • I did not see a provider during THIS visit
3 – Ensure Adequate Sample Sizes

One question we are often asked is, “How many survey submissions are required before my data is statistically valid and reliable?”.  While the answer is, “it depends” — it mainly depends on how the data is being used.  For the purposes of service improvement, a good rule-of-thumb that MedicalGPS recommends is a minimum of 30 survey responses.  Because MedicalGPS’ clients use M3-Patient Experience, which gathers patient feedback continuously, after every office visit, obtaining 30 survey responses happens rather quickly. 

4 – Collect Additional Data (if needed)

It’s important to keep in mind at what level the KPI is being used, e.g., at the provider level or at the clinic level.  Using the four KPIs above, each of those KPIs are best impacted by collaborating with the provider and then evaluating the process and workflow surrounding that provider’s specific practice.  As a result, at least 30 answers should be obtained at the provider level, for each of the four questions or KPIs.

5 – Analyze Performance Trends (Averages, Maximum Values, Minimum Values, Percentiles) 

Using historical patient experience survey data, examine performance trends over time.  For example, the M3-Patient Experience trendline graph below (Figure 1) depicts the Top Box percentage for the Message Returned Timely question.   The Top Box percentage for the Message Returned Timely question shown below is the percentage of patients that answered, “Strongly Agree”. 

The last time I left a message, my message was returned within a reasonable amount of time. (Select one)


  • Strongly Agree
  • Agree
  • Neutral (neither agree or disagree)
  • Disagree
  • Strongly Disagree
  • I have not had to leave a message recently





The maximum Top Box score over the past two years as shown in Figure 1 was recently measured at 65.63%; month-to-date for September 2022.   The minimum score was 44.67%, which occurred in November of 2021. 

Figure 1 - Message Retuned Timely

6 – Set Performance Targets and Goals

Using historical patient experience survey data, examine performance trends over time and set targeted performance goals that are “much improved, yet reasonably achievable”.  Much improved, yet reasonably achievable means setting a goal that can be obtained, but at the same time stretches the team to reach new levels of sustained customer service.  For example, using the same Message Returned Timely question performance trends, setting a targeted goal of 60% Top Box may be considered, much improved, yet reasonably achievable.  See Figure 2.

Figure 2 - Message Retuned Timely

7 – Measure, Monitor, and Modify

Using an on-going patient feedback process, continuously measure, monitor, and modify practice operations to maximize customer service levels and patient loyalty.


Physician practices that deploy and embrace the E4E service improvement program realize improvements across several M3-Patient Experience® (M3) performance metrics, including Acute Access, Message Turn-around Times, Office Wait Times, Receptionist Courteous, Telephone Handled, Recommend to Family and Friends, and other KPI metrics.

On-Demand Video Demo of M3 Patient Experience

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