NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Name

Capella university

NHS-FPX 6004 Health Care Law and Policy

Prof. Name

Date

Evaluation of Dashboard Benchmark

In this assessment, Mercy Medical Center’s dashboard data will be compared with benchmarks set by national, regional, or local laws, regulations, and guidelines for health. This comparison will help identify and resolve healthcare department issues, ensuring patient needs are met effectively. Furthermore, it will provide insight into how subpar organizational performance impacts patient care. Addressing underperformance ethically involves prioritizing the appropriate groups.

Analyzing and Evaluating Benchmark

Mercy Medical Center (MMC) in Shakopee City is renowned for its high-quality care, having received several awards for safe surgeries and outstanding patient experiences. Shakopee City has a population of 36,192, with 18,235 females and 17,957 males. The primary age group in this population is 21-44 years, comprising 14,732 individuals. MMC’s Public Health Dashboard on Diabetes provides data on eye exams, foot exams, and HbA1c tests from the first quarter of 2019 to the fourth quarter of 2020. This data includes information on new patients admitted or visiting MMC, categorized by race, gender, and age. In the last quarter of 2020, MMC admitted 563 patients.

To evaluate the effectiveness of diabetes care at MMC, it is essential to compare the dashboard metrics with the national benchmarks set by the Agency for Healthcare Research and Quality (AHRQ). According to AHRQ, the standards are 75.2% for eye exams, 84% for foot exams, and 79.5% for HbA1c tests. In the last quarter of 2020, MMC’s performance in all three tests fell short by 11% compared to these benchmarks (AHRQ, n.d.). This shortfall indicates that MMC needs to make significant improvements to meet national standards.

However, the dashboard metrics provided by MMC have several knowledge gaps and uncertainties. For instance, there needs to be more certainty regarding the credibility of the data sources and how the data was collected. Additionally, there needs to be more knowledge about the underlying factors contributing to the performance gaps in these tests, which requires further investigation to enhance evaluation and improve performance.

Consequences Not Meeting Prescribed Benchmarks

Not meeting prescribed benchmarks for diabetes care at Mercy Medical Center (MMC) can have significant and far-reaching consequences. These affect the organization’s mission, vision, resources, staffing, financial health, logistical considerations, support services, community relations, staff skills, and procedures. Failure to meet benchmarks undermines MMC’s mission to provide high-quality health care. This can lead to losing trust and credibility among patients and the community. Benchmark underperformance leads to inefficient use of resources. Inconsistent diabetes management may result in more frequent complications. This increases hospital admissions and higher resource utilization without improving patient outcomes (Zaharia et al., 2019).

Staff morale and retention can be negatively affected if benchmarks are not met. Healthcare professionals may experience increased stress and job dissatisfaction, leading to higher turnover rates (Kontoangelos et al., 2022). Recruiting skilled staff becomes challenging when an organization is perceived as underperforming. Poor performance may result in reduced funding from government programs and insurers. Inefficiencies and higher complication rates increase operational costs, straining the organization’s financial resources. Increased patient admissions due to complications from poor diabetes management can overcrowd facilities, affecting the overall quality of care provided (Tagoe et al., 2022).

Ancillary departments such as pharmacy, cleaning services, and dietary may face increased demands. This can lead to delays and reduced effectiveness in providing essential support to primary care units. Not addressing disparities in diabetes care can exacerbate health inequities. This damages the organization’s reputation and its relationship with diverse community groups. Failure to meet benchmarks may indicate gaps in staff training and skills. Continuous professional development and training programs may be needed. Inconsistent performance suggests current procedures and processes may need to be improved. Comprehensive reviews and updates to clinical protocols, patient management systems, and quality assurance processes are necessary (Karachaliou et al., 2020).

Challenges contributing to MMC’s underperformance include limited resources and funding, inadequate staffing levels, high turnover, low patient engagement, and inefficiencies in care delivery processes. Insufficient focus on culturally competent care also contributes to health disparities. Assumptions underlying this analysis include the impact of resource constraints, patient behavior, systemic issues, and the need for cultural competence. Resource constraints, both financial and human, significantly impact MMC’s ability to meet benchmarks. Patient engagement and adherence to care plans are crucial for achieving health outcomes. Systemic inefficiencies and lack of integration across departments are significant barriers to consistent diabetes management. Cultural competence and tailored interventions are essential to address health disparities among minority groups (Karachaliou et al., 2020).

The underperformance of the Benchmark

Several benchmarks estimate the quality of diabetes care, with HbA1c being the most critical as it measures patients’ blood glycemic levels. This benchmark is a diagnostic guideline for healthcare professionals to identify and diagnose diabetes, facilitating subsequent treatment planning (American Diabetes Association, 2023). Failing to monitor HbA1c levels in diabetic patients can result in severe health issues, including neuropathy, kidney failure, retinopathy, and cardiovascular diseases. According to the World Health Organization (WHO), diabetes caused 1.5 million deaths, with 48% of these deaths occurring before the age of 70 (World Health Organization, 2023). Research indicates that strict adherence to the HbA1c benchmark can reduce the incidence of retinopathy by 67%, diabetic nephropathy by 54%, cardiovascular disease risk by 35%, and peripheral neuropathy by 60% (Kaiafa et al., 2020).

The most widespread issue throughout the organization is the underperformance of HbA1c testing. Regular HbA1c testing monitors and manages blood glucose levels and prevents complications. This metric directly impacts the largest segment of MMC’s diabetes patient population, as it is a standard and critical measure for all diabetic patients. HbA1c testing affects the most significant number of patients because it is a primary diagnostic tool for managing diabetes. Inconsistent testing can lead to poor glycemic control, increasing the risk of severe complications such as neuropathy, nephropathy, retinopathy, cardiovascular diseases, and amputations. Effective diabetes management relies heavily on regularly monitoring HbA1c levels to adjust treatment plans appropriately (Alsuwayni & Alhossan, 2020).

Ensuring regular HbA1c testing aligns with MMC’s mission to provide high-quality healthcare and its vision of being a leading healthcare provider. This consistency offers multiple organizational benefits, such as improved resource utilization by reducing hospital admissions and emergency room visits, thus lowering operational costs. Financially, better performance metrics can enhance MMC’s eligibility for funding from government programs and insurers, as reimbursements are often tied to quality measures. Moreover, achieving care standards boosts staff morale and job satisfaction, leading to lower turnover rates and fewer recruitment challenges (Danaci & Koç, 2019).

The underperformance in HbA1c testing has a profound impact on the community served by MMC. Shakopee and Scott County have diverse populations, including significant minority groups such as American Indians, who already face health disparities. Inconsistent diabetes management exacerbates these disparities, leading to worse health outcomes for vulnerable populations. Poor diabetes control can result in higher rates of emergency room visits, hospital admissions, and long-term health complications, placing a more significant burden on the community and healthcare system (Bellary et al., 2021).

Standardizing and ensuring the consistent frequency of HbA1c testing presents a significant opportunity for improving the overall quality of care at MMC. Through regular testing, timely interventions and adjustments in treatment plans can be made, ultimately enhancing glycemic control and reducing the risk of complications for patients. Moreover, consistent testing can lead to more efficient resource utilization by preventing complications and reducing the need for emergency and inpatient care, thereby optimizing healthcare resources. Achieving benchmarks in HbA1c testing improves patient outcomes and boosts staff morale and efficiency, potentially reducing turnover and enhancing recruitment efforts  (Alao, 2024).

Ethical Actions for Benchmark Underperformance

To address the benchmark underperformance in HbA1c testing at Mercy Medical Center (MMC), an appropriate group of stakeholders should include hospital administration, healthcare providers, the quality improvement team, and patient advocacy groups. These stakeholders play essential roles in setting organizational priorities, delivering care, identifying areas for improvement, and advocating for patient needs. This stakeholder group must take action to improve HbA1c testing frequency due to its critical importance in managing diabetes and preventing complications. Regular testing impacts patient health outcomes, organizational reputation, and financial sustainability. Therefore, stakeholders must collaboratively work towards enhancing testing practices to ensure equitable access to high-quality diabetes care for all patients served by MMC (Imai et al., 2021).

Ethical actions that the stakeholder group can undertake include allocating adequate resources to support regular HbA1c testing, empowering patients through education about the importance of testing, implementing evidence-based protocols to streamline testing processes, and fostering collaborative decision-making to address barriers and develop sustainable solutions. These actions align with ethical principles of beneficence, non-maleficence, justice, and respect for patient autonomy. By prioritizing patient-centered care and promoting sustainability through optimized resource utilization, the stakeholder group can effectively address the benchmark underperformance in HbA1c testing, ultimately improving the overall quality of diabetes care at MMC and enhancing patient outcomes (Pourkazemi et al., 2020).

Conclusion

Improving benchmark underperformance in HbA1c testing at Mercy Medical Center demands collaborative efforts guided by ethical principles. Prioritizing patient-centered care is crucial. Optimizing resource utilization and fostering sustainability are essential steps. Through these actions, MMC can enhance diabetes management, improve patient outcomes, and uphold its commitment to high-quality healthcare.

References

AHRQ. (n.d.). NHQDR data tools – national healthcare quality and disparities reports (NHQDR). https://datatools.ahrq.gov/nhqdr/

Alao, D. (2024). Text-Based reminders: Pathways to improve hemoglobin A1C and fasting blood glucose levels of people with T2 diabetes mellitus. Doctor of Nursing Practice Projects. https://digitalcommons.andrews.edu/dnp/23/ 

Alsuwayni, B., & Alhossan, A. (2020). Impact of clinical pharmacist-led diabetes management clinic on health outcomes at an academic hospital in Riyadh, Saudi Arabia: A prospective cohort study. Saudi Pharmaceutical Journal. https://doi.org/10.1016/j.jsps.2020.11.002 

American Diabetes Association. (2023). Diagnosis | ADA. Diabetes.org. https://diabetes.org/about-diabetes/diagnosis 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Bellary, S., Kyrou, I., Brown, J. E., & Bailey, C. J. (2021). Type 2 diabetes mellitus in older adults: Clinical considerations and management. Nature Reviews Endocrinology, 17(17). https://doi.org/10.1038/s41574-021-00512-2 

Danaci, E., & Koç, Z. (2019). The association of job satisfaction and burnout with individualized care perceptions in nurses. Nursing Ethics, 27(1), 301–315. https://doi.org/10.1177/0969733019836151 

Florkowski, C. (2013). HbA1c as a diagnostic test for diabetes mellitus – reviewing the evidence. The Clinical Biochemist. Reviews, 34(2), 75–83. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3799221/ 

Imai, C., Li, L., Hardie, R.-A., & Georgiou, A. (2021). Adherence to guideline-recommended hba1c testing frequency and better outcomes in patients with type 2 diabetes: A 5-year retrospective cohort study in Australian general practice. BMJ Quality & Safety, 30(9), bmjqs-2020-012026. https://doi.org/10.1136/bmjqs-2020-012026 

Kaiafa, G., Veneti, S., Polychronopoulos, G., Pilalas, D., Daios, S., Kanellos, I., Didangelos, T., Pagoni, S., & Savopoulos, C. (2020). Is hba1c an ideal biomarker of well-controlled diabetes? Postgraduate Medical Journal, 97(1148). https://doi.org/10.1136/postgradmedj-2020-138756

Karachaliou, F., Simatos, G., & Simatou, A. (2020). The challenges in the development of diabetes prevention and care models in low-income settings. Frontiers in Endocrinology, 11(518). https://doi.org/10.3389/fendo.2020.00518

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Kontoangelos, K., Raptis, A., Lambadiari, V., Economou, M., Tsiori, S., Katsi, V., Papageorgiou, C., Martinaki, S., Dimitriadis, G., & Papageorgiou, C. (2022). Burnout related to diabetes mellitus: A critical analysis. Clinical Practice and Epidemiology in Mental Health, 18(1). https://doi.org/10.2174/17450179-v18-e2209010

Pourkazemi, A., Ghanbari, A., Khojamli, M., Balo, H., Hemmati, H., Jafaryparvar, Z., & Motamed, B. (2020). Diabetic foot care: Knowledge and practice. BMC Endocrine Disorders, 20(1), 40. https://doi.org/10.1186/s12902-020-0512-y

 Tagoe, E. T., Nonvignon, J., van Der Meer, R., Megiddo, I., & Godman, B. (2022). Challenges to the delivery of clinical diabetes services in Ghana were created by the COVID-19 pandemic. Journal of Health Services Research & Policy, 135581962211117. https://doi.org/10.1177/13558196221111708  

Zaharia, O. P., Strassburger, K., Strom, A., Bönhof, G. J., Karusheva, Y., Antoniou, S., Bódis, K., Markgraf, D. F., Burkart, V., Müssig, K., Hwang, J.-H., Asplund, O., Groop, L., Ahlqvist, E., Seissler, J., Nawroth, P., Kopf, S., Schmid, S. M., Stumvoll, M., & Pfeiffer, A. F. H. (2019). Risk of diabetes-associated diseases in subgroups of patients with recent-onset diabetes: A 5-year follow-up study. The Lancet. Diabetes & Endocrinology, 7(9), 684–694. https://doi.org/10.1016/S2213-8587(19)30187-1