NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Name

Capella university

NHS-FPX 6004 Health Care Law and Policy

Prof. Name

Date

Dashboard Metrics Evaluation 

The stakeholders at Mercy Medical Center (MMC), a renowned Vila Health-affiliated healthcare facility in Shakopee City, Minnesota, have planned to evaluate the performance dashboard against federal and state-level benchmarks in the United States. This evaluation will assess diabetes-related tests, including eye examination, foot examination, and HgBA1c laboratory investigations. 

Organization Background 

MMC stands as a beacon of high-quality healthcare in the region, consistently recognized for its exceptional service and patient care. Renowned for its safety and excellence, MMC has received numerous accolades, including the Highest Safe Surgery Rating and the Outstanding Patient Experience Award. Further solidifying its reputation, MMC was named among the Shakopee Ledger’s Top 20 Workplaces for both 2020 and 2021. Additionally, the hospital proudly holds the Women’s Choice Award for the Best Hospital for Patient Experience in Emergency Care, underscoring its commitment to providing superior and compassionate care to all patients (Capella University, n.d.).

Evaluation of Dashboard Metrics Against Benchmarks 

This evaluation employs federal-level benchmarks set forth by the Agency for Healthcare Research and Quality (AHRQ). The benchmarks for diabetes-related metrics are as follows: 

• Eye Examination: According to AHRQ, the benchmark for individuals 40 years and above who receive an annual dilated eye examination is 75.2% (AHRQ, n.d.). 
• Foot Examination: The standard of 84% is established for adults 40 years and over to have their feet examined for wounds and irritation per year (AHRQ, n.d.). 
• HgBA1c Lab Test: The benchmark for at least two HgBA1c laboratory investigations for the same age group is 79.5% (AHRQ, n.d.). 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Evaluating our performance dashboard against these benchmarks reveals significant practice gaps. Based on the total number of patients (563) in MMC, the facility had 200 eye tests in 2019 and 232 in 2020, which, according to the calculations, resulted in 35.5% and 41.2%, respectively. Secondly, MMC conducted 230 feet examinations in 2019 (40.85%) and 235 examinations in 2020 (41.7%). Finally, the organization performed 210 HgBA1c laboratory tests in 2019 and 272 in 2020, making up 37.3% and 48.3% in respective years (Capella University, n.d.).

The evaluation of MMC performance reveals significant shortfalls in diabetes-related care metrics. The percentages for eye examinations, foot examinations, and HgBA1c lab tests are considerably below the benchmarks, indicating substantial gaps in patient care and highlighting a need for targeted interventions to improve compliance with recommended diabetes care practices. However, the evaluation lacks details on the reasons for these shortfalls, such as potential barriers to patient participation and reasons behind systemic issues within MMC. Additional data on patient demographics, provider practices, and resource availability could provide a more comprehensive understanding and inform strategies for improvement.

Effects of Benchmarks Underperformance 

The benchmark underperformance at healthcare facilities has several poor consequences, significantly undermining the healthcare facilities’ mission and vision of providing high-quality, excellent care (Qin et al., 2023). Similar to other facilities, MMC strives to deliver the finest care to its patients, as indicated by the organization’s awards and accreditations. This underperformance potentially erodes patient trust and satisfaction from healthcare providers. Diabetes is a chronic health concern that requires a multifaceted treatment plan. Poor performance of diabetes-related tests may lead to complications, straining hospital resources and incurring additional costs (Kansra & Oberoi, 2023), requiring reallocation to address complicated states, which can impact other areas of care.

Financially, poor performance can lead to reduced operational and capital funding within the MMC, as reimbursements from recognized bodies are often tied to organizational performance and quality metrics (Sarkar et al., 2020). Other consequences include staffing challenges, as increased workloads can lead to burnout and turnover and limited culturally competent care. The implications of this underperformance for MMC include the need for enhanced patient education, better resource allocation, and improved staff training to meet quality care standards and maintain organizational integrity. 

Systemic challenges contributing to underperformance in MMC may include potential barriers to patient engagement, such as socioeconomic factors, language barriers, and health literacy issues. Systemic inefficiencies, like inadequate leadership commitment, lack of prioritization, and insufficient resources, also play a role in poor performance, affecting patients’ safety (Mistri et al., 2023). This analysis assumes that attaining benchmarks is crucial for every healthcare facility by employing targeted improvements to not only deliver efficient patient care but also improve the institution’s reputation within communities. 

Significantly Underperformed Benchmark 

The most critical benchmark underperformance at MMC is the low rate of eye examinations for diabetes patients, with only 35.5% in 2019 and 41.2% in 2020, against the AHRQ benchmark of 75.2% (AHRQ, n.d.; Capella University, n.d.). Given the high prevalence of diabetes, this underperformance affects a substantial number of patients. Eye examinations are vital for early detection and management of diabetic retinopathy, a leading cause of blindness (Kropp et al., 2023). Thus, the underperformance at MMC significantly impacts the community by increasing the risk of undetected diabetic retinopathy. This can result in higher disability rates, reduced quality of life, and increased healthcare costs for individuals and families. 

By increasing the rate of eye examinations in MMC, the leadership not only strives to meet the benchmark but also improves the overall quality of care at the organization. This improvement can lead to early detection and treatment of diabetic retinopathy, preventing patients from complications and disabilities and significantly enhancing quality of life (Kropp et al., 2023). Adequate patient education, streamlined follow-up procedures, and increased access to services can boost examination rates. These targeted interventions aim to improve patient outcomes, reduce long-term healthcare costs, and reinforce MMC’s commitment to high-quality care. 

Stakeholders and Actions to Address Underperformance 

To address the underperformance in diabetes eye examinations at MMC, several stakeholders are necessary, including healthcare providers, administrative leaders, patient advocacy groups, and community organizations. Healthcare providers are directly involved in patient care and education, while administrative leaders can implement systemic changes. Patient advocacy groups and community organizations can provide outreach and support to ensure widespread awareness and access. Their commitment and efforts are essential to prevent diabetes complications, particularly diabetic retinopathy, which not only compromises patients’ health but also impacts organizational financial and logistical resources (Kansra & Oberoi, 2023). Stakeholders within MMC can help reduce long-term costs, improve patient outcomes, and fulfill the organization’s mission of providing high-quality, comprehensive care. 

Ethical and Sustainable Actions 

1. Providing comprehensive patient education related to regular eye exams to prevent diabetic retinopathy increases patients’ compliance with tests, engaging them in their healthcare journey (Moinul et al., 2020). This action is guided by the ethical principle of beneficence and cultural competence, ensuring that patient education is in the best interest of patients and that materials are culturally sensitive. It is sustainable as it promotes long-term health outcomes, reducing the prevalence of diabetic retinopathy.
2. Streamlined follow-up procedures using a reminder system have proven to be effective in increasing patients’ participation in follow-up visits (Nielsen et al., 2021). This strategy, along with coordinated care plans, can improve adherence to diabetic eye screenings among patients in MMC. Guided by the ethical principle of non-maleficence to prevent harm and sustainability by optimizing healthcare resources. 
3. Finally, expanding access to services through telehealth options can address patient-related barriers to screening visits, such as transportation and financial constraints. A literature study presents that using telemedicine for retinal screening is a cost-effective method, showing a ratio of  $113 vs $3328 (Dhediya et al., 2022). Telemedicine services are grounded in the moral values of justice, ensuring fair and equal access to healthcare services and sustainability by promoting equitable health outcomes and resource optimization.

Conclusion 

In conclusion, the evaluation of Mercy Medical Center’s performance against AHRQ benchmarks highlights significant underperformance in diabetes-related screening tests, particularly eye examinations, with rates markedly below the standard. Addressing this gap offers a crucial opportunity to enhance overall care quality and patient outcomes. Stakeholders must take ethical and sustainable actions to improve performance, including patient education, streamlined follow-up procedures, and increased access to services through telemedicine, aligning with moral principles of beneficence, non-maleficence, and justice. Moreover, these efforts are sustainable, addressing immediate care needs and contributing to long-term health improvements and cost savings within the MMC and the communities it serves.

References

AHRQ. (n.d.). National Healthcare Quality and Disparities Reports (NHQDR). datatools.ahrq.gov. https://datatools.ahrq.gov/nhqdr/?tab=national&dash=282 

Capella University. (n.d.). Vila Health: Dashboard and health care benchmark evaluation. https://media.capella.edu/CourseMedia/nhs6004element17010/wrapper.asp?&sso=true

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Dhediya, R., Chadha, M., Bhattacharya, A. D., Godbole, S., & Godbole, S. (2022). Role of telemedicine in diabetes management. Journal of Diabetes Science and Technology, 17(3), 193229682210811. https://doi.org/10.1177/19322968221081133 

Kansra, P., & Oberoi, S. (2023). Cost of diabetes and its complications: Results from a STEPS survey in Punjab, India. Global Health Research and Policy, 8(1). https://doi.org/10.1186/s41256-023-00293-3

Kropp, M., Golubnitschaja, O., Mazurakova, A., Koklesova, L., Sargheini, N., Steve, K., de Clerck, E., Polivka, J., Potuznik, P., Polivka, J., Stetkarova, I., Kubatka, P., & Thumann, G. (2023). Diabetic retinopathy as the leading cause of blindness and early predictor of cascading complications—risks and mitigation. EPMA JOURNAL, 14(1), 21–42. https://doi.org/10.1007/s13167-023-00314-8 

Mistri, I. U., Badge, A., Shahu, S., Mistri, I. U., Badge, A., & Shahu, S. (2023). Enhancing patient safety culture in hospitals. Cureus, 15(12), 1–7. https://doi.org/10.7759/cureus.51159 

Moinul, P., Barbosa, J., Qian, J., Chen, M. L., Mohaghegh, M., Kaur, H., Holmes, J., Radman, H., Robinson, T., & Chaudhary, V. (2020). Does patient education improve compliance to routine diabetic retinopathy screening? Journal of Telemedicine and Telecare, 26(3), 161–173. https://doi.org/10.1177/1357633×18804749

Nielsen, J. H., Melendez-Torres, G. J., Rotevatn, T. A., Peven, K., Fonager, K., & Overgaard, C. (2021). How do reminder systems in follow-up screening for women with previous gestational diabetes work? – a realist review. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06569-z 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Qin, X., Wang, B.-L., Zhao, J., Wu, P., & Liu, T. (2023). Learn from the best hospitals: A comparison of the mission, vision and values. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09699-8

Sarkar, R. R., Courtney, P. T., Bachand, K., Sheridan, P. E., Riviere, P. J., Guss, Z. D., Lopez, C. R., Brandel, M. G., Banegas, M. P., & Murphy, J. D. (2020). Quality of care at safety‐net hospitals and the impact on pay‐for‐performance reimbursement. Cancer, 126(20), 4584–4592. https://doi.org/10.1002/cncr.33137