Write a 3-5 page report for a senior leader that communicates your evaluation of current organizational or interprofessional team performance, with r
Write a 3-5 page report for a senior leader that communicates your evaluation of current organizational or interprofessional team performance, with respect to prescribed benchmarks set forth by government laws and policies at the local, state, and federal levels.
In the era of health care reform, many of the laws and policies set forth by government at the local, state, and federal levels have specific performance benchmarks related to care delivery outcomes that organizations must achieve. It is critical for organizational success that the interprofessional care team is able to understand reports and dashboards that display the metrics related to performance and compliance benchmarks.
Maintaining standards and promoting quality in modern health care are crucial, not only for the care of patients, but also for the continuing success and financial viability of health care organizations. In the era of health care reform, health care leaders must understand what quality care entails and how quality in health care connects to the standards set forth by relevant federal, state, and local laws and policies. Understanding relevant benchmarks that result from these laws and policies and how they relate to quality care and regulatory standards is also vitally important.
Health care is a dynamic, complex, and heavily regulated industry. For this reason, you will be expected to constantly scan the external environment for emerging laws, new regulations, and changing industry standards. You may discover that as new policies are enacted into law, ambiguity in interpretation of various facets of the law may occur. Sometimes, new laws conflict with preexisting laws and regulations, or unexpected implementation issues arise, which may warrant further clarification from lawmakers. Adding partisan politics and social media to the mix can further complicate understanding of the process and buy-in from stakeholders.
Choose one of the following two options for a performance dashboard to use as the basis for your evaluation:
Option 1: Dashboard Metrics Evaluation Simulation
Use the data presented in your Assessment 1 Dashboard and Health Care Benchmark Evaluation activity as the basis for your evaluation.
Note: The writing you do as part of the simulation could serve as a starting point to build upon for this assessment.
Option 2: Actual Dashboard
Use an actual dashboard from a professional practice setting for your evaluation. If you decide to use actual dashboard metrics, be sure to add a brief description of the organization and setting that includes:
- The size of the facility that the dashboard is reporting on.
- The specific type of care delivery.
- The population diversity and ethnicity demographics.
- The socioeconomic level of the population served by the organization.
Note: Ensure your data are Health Insurance Portability and Accountability Act (HIPAA) compliant. Do not use any easily identifiable organization or patient information.
To complete this assessment:
- Review the performance dashboard metrics in your Assessment 1 Dashboard and Health Care Benchmark Evaluation activity, as well as relevant local, state, and federal laws and policies. Consider the metrics that are falling short of the prescribed benchmarks. Note: The writing you do as part of the simulation could serve as a starting point to build upon for this assessment.
- Write a report for a senior leader that communicates your evaluation of current organizational or interprofessional team performance, with respect to prescribed benchmarks set forth by government laws and policies at the local, state, and federal levels. In addition, advocate for ethical and sustainable action to address benchmark underperformance and explain the potential for improving the overall quality of care and performance, as reflected on the performance dashboard.
- Make sure your report meets the Report Requirements listed below. Structure it so that it will be easy for a colleague or supervisor to locate the information they need, and be sure to cite the relevant health care policies or laws when evaluating metric performance against established benchmarks.
REPORT REQUIREMENT
The report requirements outlined below correspond to the scoring guide criteria, so be sure to address each main point. Read the performance-level descriptions for each criterion to see how your work will be assessed. In addition, be sure to note the requirements for document format and length and for supporting evidence.
- Evaluate dashboard metrics associated with benchmarks set forth by local, state, or federal health care laws or policies.
- Which metrics are not meeting the benchmark for the organization?
- What are the local, state, or federal health care policies or laws that establish these benchmarks?
- What conclusions can you draw from your evaluation?
- Are there any unknowns, missing information, unanswered questions, or areas of uncertainty where additional information could improve your evaluation?
- Analyze the consequence(s) of not meeting prescribed benchmarks and the impact this has on health care organizations or teams.
- Consider the following examples:
- Organizational mission and vision.
- Resources.
- Staffing.
- Financial: Operational and capital funding.
- Logistical considerations: Physical space.
- Support services (any ancillary department that gives support to a specific care unit in the organization, such as pharmacy, cleaning services, dietary, et cetera).
- Cultural diversity in the community.
- Staff skills.
- Procedures and processes.
- Address the following:
- What are the challenges that may potentially contribute to benchmark underperformance?
- What assumptions underlie your conclusions?
- Consider the following examples:
- Evaluate a benchmark underperformance in a heath care organization or interprofessional team that has the potential for greatly improving overall quality or performance.
- Focus on the benchmark you chose to target for improvement. Which metric is underperforming its benchmark by the greatest degree?
- State the benchmark underperformance that is the most widespread throughout the organization or interprofessional team.
- State the benchmark that affects the greatest number of patients.
- Include how this underperformance will affect the community that the organization serves.
- Include the greatest opportunity to improve the overall quality of care or performance of the organization or interpersonal team and, ultimately, to improve patient outcomes, as you think about the issue and the current poor benchmark outcomes.
- Advocate for ethical and sustainable action(s), directed toward an appropriate group of stakeholders, needed to address a benchmark underperformance.
- Who would be an appropriate group of stakeholders to act on improving your identified benchmark metric?
- Why should the stakeholder group take action?
- What are some ethical actions the stakeholder group could take that support improved benchmark performance?
- Organize content so ideas flow logically with smooth transitions.
- Proofread your report, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your evaluation and analysis.
- Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
· Competency 1: Analyze relevant health care laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
· Analyze the consequence(s) of not meeting prescribed benchmarks and the impact this has on health care organizations or teams.
· Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
· Advocate for ethical and sustainable action(s), directed toward an appropriate group of stakeholders, needed to address a benchmark underperformance.
· Competency 3: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, to inform health care laws and policies for patients, organizations, and populations.
· Evaluate dashboard metrics associated with benchmarks set forth by local, state, or federal health care laws or policies.
· Evaluate a benchmark underperformance in a health care organization or interprofessional team that has the potential for greatly improving quality or performance.
· Competency 5: Produce clear, coherent, and professional written work, in accordance with Capella's writing standards.
· Organize content so ideas flow logically with smooth transitions.
· Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
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1
Dashboard Benchmark Evaluation
Tabitha Ashbrook
Capella University
NURS-FPX6004
Dr. Aciel Sagrera-Mulen
October 4, 2023
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Dashboard Benchmark Evaluation
In Shakopee, Minnesota, Mercy Medical is known for the quality of healthcare the
patients receive. Mercy Medical has analyzed its data related to its diabetes client community
health dashboard, and this assessment will help to determine if they are performing adequately
with this population. Dashboards such as these allow us to see if they are performing well or not.
The standards are set by legislation throughout the region, statewide and federally.
Evaluating Benchmarks
In 2020, Mercy Medical saw 563 patients for diabetes-related exams. When looking at
race, Mercy Medical was primarily visited by those of either Caucasian, American Indian, or
Asian descent. The three exams that were done were the eye, foot, and HgbA1c exams. The two
areas with the biggest concerns include the eye and foot exams.
According to the American Diabetes Association regarding eye exams, “people with type
2 diabetes should have an initial dilated and comprehensive eye exam at the time of the diabetes
diagnosis” (ADA, 2023). According to Mercy Health’s data on eye exams, their total for the
year 2019 was only two hundred. Compared with 2020, two hundred thirty-two eye exams
occurred, a 16% increase in eye examinations. The fourth quarter had the lowest number of
examinations done, which is forty-two exams, however, most of the other quarters stayed fairly
consistent between forty-eight and sixty-four exams. In Shakopee, Minnesota, it is recorded that
only 7% of residents over the age of eighteen were recorded to be diagnosed with diabetes, while
in all of Minnesota, 7.8% had diabetes (CDC, n.d.). According to NHQDR reports, “adults 40
years of age and older with diagnosed diabetes who received a dilated eye examination in the
calendar year” were rated in 2019 for a 73.1% compliance rate, which decreased from their
baseline in 2013 of 74.9% (National Healthcare Quality and Disparities Reports, 2019).
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Related to foot care, the American Diabetes Association recommends a foot evaluation to
“identify risk factors for ulcers and amputations” (ADA, 2023). At Mercy Health, in 2020, only
two hundred and thirty-five received a foot examination out of 563 patients. However, in 2019,
only two hundred and thirty patients received foot examinations. This comes to an increase of
just 2.13% between 2019 and 2020 total foot examinations. According to the same report as for
the eye examinations, in 2019, the state of Minnesota measured “adults aged 40 and year who
were diagnosed with diabetes who had their feet checked for sores and irritation in the calendar
year,” and the rate for 2019 was 82.9% compliance, which is higher than their baseline from
2013 of 87.7% (National Healthcare Quality and Disparities Reports, 2019).
Analysis of Benchmarks
The benchmark that has been set for the diabetic population related to receiving eye
examinations is 75.2%. The benchmark that has been set for the diabetic population related to
receiving foot examinations is 84% (National Healthcare Quality and Disparities Reports, 2019).
Based on the information the dashboard of Mercy Health is extracting, Mercy Health is not
meeting the benchmarks based on what has been set by federal, state, and local legislations.
Because of this, there is room for improvement within this community to educate the importance
of diabetic care, examinations of the feet and eyes, as well as having their HgbA1C checked
twice annually. For 2020, the total number of patients who received an eye exam is two hundred
and thirty-two patients. When you divide this by five hundred and sixty-three, 0.41%, or 41%
after multiplying by 100, to see where in benchmark ratings Mercy Health would be rated for eye
examinations. Furthermore, when you do these calculations with those who received foot
examinations, you come to a 42% benchmark rating. In conclusion, both ratings do not meet the
benchmarks set for eye and foot examinations.
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Challenges toward the Benchmarks
Based on the data we have received from Mercy Health, we only have data related to
their age, gender, and race, however, we do not see other pertinent demographics such as income,
if they hold insurance, or their economic status to know if these examinations can be obtained.
After the 2010 enactment of the Affordable Care Act, it was found that “newly insured patients
had greater improvements in diabetes-related biomarkers than continuously uninsured,
discontinuously insured, or continuously insured patients” (Marino et al., 2020, p. 2080).
Ethical and Sustainable Actions Needed
It is imperative that Mercy Health provide more education related to diabetes, foot, and eye
examinations, and Hgb1Ac. As healthcare providers, it is our ethical duty to provide education
and inform the patient of the risks and benefits of all courses of treatment. However, one of the
ethical principles is beneficence, which refers to ‘doing good’ and we do this by acting in the
best interest of the patient, which includes giving pertinent education and resources based on
their diagnosis. In this case, it is diabetes, and Mercy Health is strongly lacking with its diabetes
population. There may be many barriers to patients coming to receive care and the hospital
meeting benchmarks, such as language barriers, patient race, insurance, financial status, level of
education or lack thereof, or simply a lack of knowledge related to their diagnosis. According to
the Minnesota Department of Health, “Around 1 in 10 people with diabetes do not know they
have the disease” (Minnesota Department of Health, 2022).
Improving Performance Related to Examinations
Mercy Medical is showing numerous decreases in multiple quarters between 2019
and 2020 in both eye and foot examinations. While a loss of vision could lead to blindness if the
disease is not controlled, foot examinations must remain a priority, as infection can lead to more
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serious complications. Because of having diabetes, patients are already at an increased risk of
delayed wound healing. Furthermore, they typically have diabetic neuropathy which increases
the already great risk of infection quickly leading to sepsis. It is the responsibility of the
provider or nurse to educate the patient on foot care, what kind of shoes to wear, how often to
assess their feet for any sores, unknown drainage, or redness, and when to go to the emergency
room if they have an infection or find an unnatural finding such as a nail in their foot. Proper
education could significantly impact a patient’s knowledge of diabetes and may increase Mercy
Health’s rate of eye and foot examinations, and then would meet benchmarks accordingly. One
article states, “Diabetic retinopathy (DR) is among the leading causes of vision loss in the US”
and also states that “patients with diabetes and low socioeconomic status or who are racial/ethnic
minorities are at increased risk for vision loss” (Fairless et al., 2019, p. 1244). With diabetic foot
complications, “Around 25% of all patients with diabetes develop foot complications during
their course of disease” (Rossboth et al., 2020). From this same source, it is reported that
“diabetic foot ulcers (FU) and amputations make up the most expensive diabetic late
complication in terms of hospital costs.”
Conclusion
National benchmarks are set to show the standard of care expected for each hospital or
other facility to meet regarding patient care. Mercy Medical Center has been found to not meet
benchmarks set related to its diabetic population of patients. This will require great effort from
all of the healthcare staff who have diabetic patients or even pre-diabetic patients to educate a
substantial amount on the importance of receiving care when required. There is potential for
infection, sepsis, vision loss, neuropathy, and death if this disease is not well-controlled. It is
also important for healthcare providers to educate patients on how to do proper foot
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examinations at home to their ability. It is also important to educate noncompliant patients on
the importance of compliance, and we must make all patients aware of the risks and benefits of
compliance with treatment set by medical professionals.
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References
American Diabetes Association. (2023).
https://diabetesjournals.org/clinical/article/41/1/4/148029/Standards-of-Care-in-Diabetes-
2023-Abridged-for
Diabetes in Minnesota. (n.d.). Diabetes in Minnesota – MN Dept. of Health. Retrieved 2023,
from https://www.health.state.mn.us/diseases/diabetes/data/diabetesfacts.html
Fairless, E., & Nwanyanwu, K. (2019). Barriers to and facilitators of diabetic retinopathy
screening utilization in a high-risk population. Journal of Racial and Ethnic Health
Disparities, 6(6), 1244–1249. https://doi.org/10.1007/s40615-019-00627-3
Marino, M., Angier, H., Springer, R., Valenzuela, S., Hoopes, M., O’Malley, J., Suchocki, A.,
Heintzman, J., DeVoe, J., & Huguet, N. (2020). The affordable care act: Effects of
insurance on diabetes biomarkers. Diabetes Care, 43(9), 2074–2081.
https://doi.org/10.2337/dc19-1571
National Healthcare Quality and Disparities Reports (NHQDR). (n.d.).
Rossboth, S., Lechleitner, M., & Oberaigner, W. (2020). Risk factors for diabetic foot
complications in type 2 diabetes—a systematic review. Endocrinology, Diabetes &
Metabolism, 4(1). https://doi.org/10.1002/edm2.175
Surveillance – united states diabetes surveillance system. (n.d.).
https://gis.cdc.gov/grasp/diabetes/diabetesatlas-surveillance.html
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1
Dashboard Metrics Evaluation
Taylor Schwer
School of Nursing and Health Sciences, Capella University
NHS-FPX6004: Health Care Law and Policy
Aciel Sagrera- Mulen
October, 2023
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Evaluation of Dashboard Metrics related to Benchmarks
Carrying out benchmarking is an important part in any industry but is especially
important in the healthcare industry to allow continued improvement in the care that patients are
receiving which can be done by comparing within the company as well as comparing with
competitor’s standards (Miner, 2019). Due to the importance of this monitoring plan, it is crucial
for companies and businesses to thoroughly review the information gained from this to
determine which areas are not meeting the benchmarks that are being set and how this is
impacting the company/ clients. This letter is to inform you of the areas that are below the set
benchmark currently and what can be done to improve those lacking areas.
Evaluation Process
Upon reviewing the metrics from the Mercy Medical Center’s Public Health Dashboard,
there are a few areas that are not meeting the proposed benchmarks that can be improved upon to
better the hospital. Specifically, the two largest areas of concern include the decline in HbgA1C
checks as well as the decrease in foot exams. Both of these areas are very important to diabetic
care to ensure that potential complications from the disease are found early.
There is some important information that is missing from the dashboard metrics though
that may play an important role in improving these areas of concern. For example, we do not
know the reasons for declining exams if it is that there are less available appointments for these
patients to be seen, if there is a transportation issue with the patients trying to get to the clinic for
exam, etc. If there was more information that indicated what the possible reason for this decrease
was, it would be helpful in creating a way to improve the decline.
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Consequences of Failing to Meet Benchmarks
86% of healthcare agencies will increase their program’s effectiveness/ efficiency by
carrying out a quality improvement project (Centers for Disease Control and Prevention, 2023).
These quality improvement projects are created by assessing the benchmarks that are not being
met and finding ways to work on improving those lacking areas. By continuing to not meet the
necessary benchmarks set by the company, there can be many departments impacted. For the
specific benchmark we are discussing with diabetic care, areas such as financial and support
services may be impacted.
From a financial perspective, if patients are not receiving the necessary preventative care
for diabetes, such as the Foot Exams, this can lead to a higher expense for the patient’s insurance
in the future. With diabetes, the significant nerve damage that can be caused from the disease,
can lead patients to be unable to identify pain, heat or cold which could allow the patient to have
a severe injury that they are not aware of that could lead to a more serious issue (American
Diabetes Association, n.d). For example, if the patient develops a cut or blister on the bottom of
their foot that they cannot feel and no one is evaluating, that patient may develop a serious
infection which could be serious and even result in sepsis or amputation depending on how long
it goes prior to being identified. This financial cost would be greatly different than if the patient
were participating in regular foot exams at which time this cut could be identified early prior to
becoming infected.
This may also impact supportive services as well. With the hospital having a diabetes
clinic and having individuals assessing the patients, if there are not patients using the services,
this may impact their jobs as well. There are many reasons that could be contributing to the
services not being used. Diabetes, as previously mentioned can have an effect on the feeling in
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people’s feet as well as risk of hypoglycemic events that may make individuals more likely to
not want to drive. It is also shown that type II diabetes affects, 10.9 million US adults who are
over the age of 65 years old which is expected to continue to increase significantly by 2050
(Chentli, Azzoug, & Mahgoun, 2015). As individuals age, they may also start to have a more
difficult time with transportation which may also affect them getting care.
Stakeholder Investment
One of the most important stakeholders who would be able to help in this situation would
be insurance companies. They are invested in the patients and are invested in preventative care
that will cost them less money on the future on serious health issues. It would be extremely
beneficial for them to invest in this improvement so that the patients are getting this necessary
care in the preventative stage instead of having huge health care costs when these serious
conditions progress to more serious issues down the road. It is shown that 48% to 64% of total
medical costs for someone with diabetes are related to complications from the disease (Centers
for Disease Control and Prevention, 2022). If the patients are being seen more frequently for
preventative care, this number can be decreased for care.
To help increase compliance with foot exams for diabetic patients, insurance could
sponsor more options for the exams through the local hospitals, including Mercy Medical Center.
One of these options could be providing tablets to patients who are having issues with
transportation and are at high risk of not being compliant with exams.
In conclusion, foot exams are below benchmark for Mercy Medical Center during this
years evaluation. The drop in the foot exams for diabetic patients can lead to many additional
issues with the patients and their care. Therefore, it is extremely important to the patients, the
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health system and an important stakeholder- the insurance companies, to ensure this preventative
care is being met.
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References
American Diabetes Association. (n.d.). Diabetes foot care tips. Diabetes Foot Care Tips | ADA.
https://www2.diabetes.org/healthy-living/seniors/foot-care-
tips#:~:text=Taking%20care%20of%20your%20feet,blister%20until%20it%20gets%20in
fected.
Centers for Disease Control and Prevention. (2022). Health and economic benefits of diabetes
interventions. Centers for Disease Control and Prevention.
https://www.cdc.gov/chronicdisease/programs-
impact/pop/diabetes.htm#:~:text=Among%20Medicare%20beneficiaries%20aged%2065,
%245%2C876%20per%20person%20each%20year.&text=48%25%20to%2064%25%20
of%20lifetime,as%20heart%20disease%20and%20stroke.
Centers for Disease Control and Prevention. (2023). CDC – NPHII – STLT Gateway. Centers for
Disease Control and Prevention.
https://www.cdc.gov/publichealthgateway/nphii/index.html
Chentli, F., Azzoug, S., & Mahgoun, S. (2015). Diabetes mellitus in elderly. Indian journal of
endocrinology and metabolism, 19(6), 744–752. https://doi.org/10.4103/2230-
8210.167553
Miner, Crystal,M.B.A.-H.S.A., F.A.C.M.P.E. (2019). Benchmarking in Healthcare: Steps for
Improvement. The Journal of Medical Practice Management: MPM, 34(5), 272-274.
http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fscholarly
-journals%2Fbenchmarking-healthcare-steps-
improvement%2Fdocview%2F2504872253%2Fse-2%3Faccountid%3D27965
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