NHS-FPX6004 Benchmark Underperformance Dashboard Metrics ExampleBenchmark Underperformance Dashboard

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NHS-FPX6004 Benchmark Underperformance Dashboard Metrics Example

Benchmark Underperformance Dashboard Metrics Example

Benchmark Underperformance Dashboard Metrics Example

Benchmark Underperformance

Name

Institution

Benchmark Underperformance

Healthcare dashboards are crucial in determining the organization’s performance and indicators of quality. Dashboards and reports on performance provide critical information on how well the organization is performing on different fronts Benchmark Underperformance Dashboard Metrics Example. A digital dashboard such as Mercy Medical Center is sharable and can be used in outlining gaps in performance and implementing the necessary interventions to improve health care organization performance and quality of care.

Understanding benchmark underperformance as highlighted in local, state, and federal government policies and benchmarks will ensure effective quality improvement and improved outcomes in care Benchmark Underperformance Dashboard Metrics Example. This paper is an evaluation of Mercy Medical Center (Shakopee, MN) dashboard to outline areas of underperformance and suggest ethical action towards meeting set benchmarks.

Evaluation of Dashboard Metrics

After evaluation of the dashboard, several aspects have been noted with the patient records and trends in the organization. Two major areas of concern can be seen in this data; low HgbA1c tests and foot exam rates Benchmark Underperformance Dashboard Metrics Example. The highest number of foot exam rates indicated in the dashboard was 73 in 2019 Q1 and this declined to only 3 in Q4 of the same year (Vila Health, n.d.). HgbA1c test rates have also declined notably from 123 in 2019 Q1 to only 6 in Q4 (Vila Health, n.d.).

These tests are important in monitoring glycemic control as well as diabetes complications and hence the decline in testing rates presents a major health concern Benchmark Underperformance Dashboard Metrics Example. The tests are considered crucial in preventing diabetes complications and hence decline in the rates of tests shows poor outcomes.

When comparing these two areas of assessment with the state and national benchmarks, it is evident that they fail to meet the benchmark for both state and national outcomes. The numbers provided in the dashboard have not indicated percentages hence a major assumption made here is that the highest number is the total of diabetes patients. Assuming that the total number of patients is 123, only 6 (48.7%) received the HgbA1c tests in Q4 2019 compared to the national benchmark of 79.5%.

The state benchmark for Minnesota is 78.0% hence HgbA1c tests fall below both benchmarks (AHRQ, 2020). Similarly, in foot examinations, only 3 (24.4%) were examined in 2019 Q4 which falls below the national benchmark of 84.0% and Minnesota benchmark of 84.1% (AHRQ, 2020). Benchmark Underperformance Dashboard Metrics Example Therefore, when compared with the state and national rates, testing for diabetes-related complications at Mercy Medical fails to meet the required benchmarks.

The benchmarks against which this performance is compared are based on the National Healthcare Quality and Disparities Reports by the Agency for Healthcare Research and Quality (AHRQ). The agency derives the measures from top-performing states to compare achievable benchmarks with the performance of the rest of the country (AHRQ, 2020). These comparisons are used as part of the AHRQ agenda for continuous improvement and the Centers for Medicare and Medicaid Services (CMS) incentives to states and hospital organizations.

The data on Mercy Medical Center’s Dashboard also presents several areas of uncertainty where more information would help. For example, data on new diabetes patients is incomplete since the dashboard does not indicate the total new numbers in previous quarters. Similarly, the numbers of practitioners and facilities reported do not have comparators hence one cannot accurately tell whether the resources are adequate for the practice. More information on acuity and utilization level for the staff and facilities respectively would help in assessing the adequacy of resources in the organization. Benchmark Underperformance Dashboard Metrics Example

Challenge in Achieving Acceptable Performance

Several challenges may be experienced in achieving acceptable performance and for Mercy Medical Center, resources may be one of the biggest challenges Benchmark Underperformance Dashboard Metrics Example. The identified performance gaps include decline in testing and examination rates for patients with diabetes. Improvement in these performance areas would require more education and outreach to patients with diabetes.

Resources required for such an intervention include community education and facilitation resources as well as training finances required for the training processes. Benchmark Underperformance Dashboard Metrics Example

The high demands for resources and finances would thus present a challenge for the organization in improving current performance. Lack of resources means that the medical center does not provide enough education to the community and hence fewer people get tested and examined for diabetes complications Benchmark Underperformance Dashboard Metrics Example. The assumption made in this analysis is that the organization does not have a current diabetes education program in Shakopee, MN.

 Specific Target for Improvement

The dashboard presents many areas of improvement which medical center can focus its efforts to produce better results and achieve the best overall improvement in quality outcomes. Areas of improvement can be chosen based on severity of the issue, number of affected patients, financial impact, and stakeholders involved in the process Benchmark Underperformance Dashboard Metrics Example. A crucial area of improvement is the testing and evaluation of diabetes and diabetes-related conditions.

According to the American Diabetes Association (2017), early detection of diabetes complications can aid in reducing the progress of the condition and hence significantly improving the quality of life for the patients Benchmark Underperformance Dashboard Metrics Example. Eye examination, foot evaluation, and HgbA1c tests are crucial areas of improvement since they enhance the quality of care for patients with diabetes and hence produce better health outcomes.

Another area of improvement that can be outlined in the medical center is the staffing levels. Although the dashboard does not clearly indicate gaps in staffing rates at Mercy Medical Center, staffing is one of the crucial areas of improvement that healthcare organizations in general should consider. This is because staffing levels and burnout rates are correlated with the quality of care and patient satisfaction (Gillet et al., 2018).

Staffing levels also affects a huge number of stakeholders starting with the patients, staff, and even the management. It is thus justifiable that the organization should focus on improving staffing levels hence enhancing care quality and outcomes Benchmark Underperformance Dashboard Metrics Example. The proposed improvement should thus focus on proactive diabetes care as well as staffing levels to improve care quality and reduce underperformance gap. Benchmark Underperformance: Dashboard Metrics Example

Suggested Actions for Performance Improvement

Based on the evaluation, it becomes evident that ethical action should be implemented to enhance the quality of care in Mercy Medical Center. The proposed ethical action is two-pronged. The first approach is to carry out patient education on diabetes care for reducing complications. This education program will target the community in general and also focus on diabetic patients specifically.

Community-targeted diabetes education reduces diabetes complications and adherence to treatment plan (Kwan et al., 2020). The education project could include community-based programs and in-clinic education approaches. The action is considered ethical because it increases patients’ health knowledge and will increase self-care and continuity in diabetes management. Benchmark Underperformance Dashboard Metrics Example

The second aspect of care improvement is assessing staffing needs and improving current staffing levels to support quality improvement. Staffing needs can be assessed through an overview of nurse acuity and provider: patient ratios in the organization. The staffing needs assessment will then be followed by a recruitment and training program to equip the organization with the relevant staff resources required to deliver high quality care.

The impact of this project will be positive quality-wise and will also benefit staff and patients. Better staffing levels will reduce burnout and increase job satisfaction while providing the relevant expertise and workforce for quality care and improvement Benchmark Underperformance Dashboard Metrics Example. Therefore, combining staffing improvements with diabetes education will significantly improve the quality of care and performance at Mercy Medical Center.

Benchmark Underperformance Dashboard Metrics Example Conclusion

The dashboard analysis is useful in determining areas of underperformance and pinpointing the need for improvement in the health care organization. This deliverable has shown that Mercy Medical Center could improve the quality of care by enhancing patient knowledge about diabetes-related examinations and tests. Also, improved staffing levels are useful in facilitating overall care quality improvement. The dashboard analysis provides a basis for care improvement and enhances quality outcomes by justifying interventions in the health care organization. Benchmark Underperformance Dashboard Metrics Example

Benchmark Underperformance Dashboard Metrics Example References

1. Agency for Healthcare Research and Quality (AHRQ). (2020). Minnesota: Diabetes Quality Measures Compared to Achievable Benchmarks. National Healthcare Quality and Disparities Reports. https://nhqrnet.ahrq.gov/inhqrdr/Minnesota/benchmark/table/Diseases_and_Conditions/Diabetes
2. American Diabetes Association. (2017). 10. Microvascular complications and foot care. Diabetes Care, 40(Supplement 1), S88-S98. https://doi.org/10.2337/dc17-S013
3. Gillet, N., Fouquereau, E., Coillot, H., Cougot, B., Moret, L., Dupont, S., … & Colombat, P. (2018). The effects of work factors on nurses’ job satisfaction, quality of care and turnover intentions in oncology. Journal of Advanced Nursing, 74(5), 1208-1219. https://doi.org/10.1111/jan.13524
4. Kwan, B. M., Dickinson, L. M., Glasgow, R. E., Sajatovic, M., Gritz, M., Holtrop, J. S., … & Waxmonsky, J. A. (2020). The Invested in Diabetes Study Protocol: a cluster randomized pragmatic trial comparing standardized and patient-driven diabetes shared medical appointments. Trials, 21(1), 65. https://doi.org/10.1186/s13063-019-3938-7
5. Vila Health. (n.d.). Dashboard and Health Care Benchmark Evaluation. Capella University. https://media.capella.edu/CourseMedia/nhs6004element17010/wrapper.asp

Benchmark Underperformance: Dashboard Metrics Example Instructions

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.
• Benchmark Underperformance Dashboard Metrics Example

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:

1. 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.
2. 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.
3. 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.
4. Benchmark Underperformance Dashboard Metrics Example

Report Requirements

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?
• 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.
  • Be sure to apply correct APA formatting to source citations and references.
  • Benchmark Underperformance Dashboard Metrics Example

Report Format and Length

Format your report using APA style.

• Use the APA Style Paper Tutorial [DOCX] to help you in writing and formatting your report. Be sure to include:
  • A title and references page. An abstract is not required.
  • Appropriate section headings.
• Your report should be 3–5 pages in length, not including the title page and references page.

Supporting Evidence

Cite 4–6 credible sources from peer-reviewed journals or professional industry publications to support your analysis of challenges, evaluation of potential for improvement, and your advocacy for ethical action.

Dashboard and Health Care Benchmark Evaluation

Dashboards and other reports can provide crucial information about how well an organization is meeting benchmarks set by local, state, and federal laws and policies. Healthcare organizations need to be able to use this information to determine the most effective strategies for quality and performance improvement. This activity asks you to review a diabetes dashboard and fact sheet used by Mercy Medical Center, a Vila Health affiliated hospital, and determine where the organization is falling short.

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Scatterdesk

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Public Health Dashboard – Diabetes

New Patients Last Quarter by Race

• African American – 17 (3 percent)
• American Indian – 73 (13 percent)
• Asian – 34 (6 percent)
• White – 355 (63 percent)
• Other – 11 (2 percent)
• Blank/Declined – 73 (13 percent)

New Patients Last Quarter by Gender

• Male – 214 (38 percent)
• Female – 347 (62 percent)
• Blank/Declined – 2

New Patients Last Quarter by Age

• 20 or younger – 118 (21 percent)
• 21-39 – 51 (9 percent)
• 40-64 – 214 (38 percent)
• 65+ – 180 (32 percent)
• Blank/Declined – 0

Q1 2019Q2 2019Q3 2019Q4 2019Q1 2020Q2 2020Q3 2020Q4 2020Eye Exam5048604262485864Foot Exam6058427075504862HgbA1c6048604272587864

Fact Sheet

Mercy Medical Center (Shakopee, MN)

Mercy Medical Center is one of the region’s top choices for high quality health care. Don’t just take our word for it, though. Here are some of the accolades we’ve received:

• Highest Safe Surgery Rating by a consumer advocacy magazine.
• Healthgrades Outstanding Patient Experience Award.
• Shakopee Ledger Top 20 Workplaces 2020 and 2021.
• Women’s Choice Award for the Best Hospital for Patient Experience in Emergency Care.

Shakopee Demographics

FemaleMaleTotal Population18,23517,95736,192< 2021-4445-64> 6512,12614,7326,0992,371WhiteAsianHispanic – LatinoOtherAfrican AmericanTwo or more racesAmerican Indian28,537 (76 percent)3,822 (10 percent)2,890 (7 percent)1,661 (4 percent)1,601 (4 percent)1,016 (4 percent)433 (1 percent)

Shakopee Ledger

Top 20 Workplaces 2020 & 2021

20102021Hospital Rooms (All Private)62 (70 licensed)85 (93 licensed)Medical/Surgical Rooms3356Special Care Unit88Family Birth Rooms1717Children’s Care Pediatric Rooms44Operating Rooms5 and 1 C – Section8 and 1 C – SectionEmergency Room Treatment Bays1621Endoscopy Rooms222021Physicians433Volunteers (15 — 94 years old)200Inpatient Admissions5,735Surgical Procedures4,627Births1,328Emergency Room Visits29,893Urgent Care Visits9,586Outpatient Encounters119,535Physical, Occupational, Speech/Language Therapy Visits28,636Pediatric Therapy Visits11,987Sleep Center Visits783Radiology Procedures59,335Cardiac Rehab Visits7,158Cardiopulmonary Visits19,676Cancer Center Visits7,781

Now that you’ve reviewed the data answer the following questions:

What are the biggest areas of concern with regards to the information in Mercy Medical Center’s Public Health Dashboard – Diabetes?

Your response:

This question has not been answered yet.

While there are a few areas of concern present in the diabetes public health dashboard, the two biggest areas of concern are the declining HgbA1c exams and the low foot exam rate. Both of these tests are important tests to help identify potential diabetes related complications early. Benchmark Underperformance Dashboard Metrics Example

Some areas that are not concerns, or there is not enough data to say for sure are as follows

The number of eye exams has fluctuated over the last two years. It is about 6 times what it was in first quarter of 2018. and it is four to nine times more than the foot and HgbA1c exams. It could probably be better, but it is not one of the biggest areas of concern.

With regard to the data on new diabetes patients, this dashboard has no information on the total number of new patients in previous quarters. So the new patient numbers cannot definitively be called an issue based on the data available.

Looking at the statement regarding patients aged 20 or younger, similar to the new patient statement, there is not enough data within this dashboard to label it as one of the biggest areas of concern.

Select one of the underperforming metrics. Why and how would improving this metric contribute to the overall success of Mercy Medical Center? Benchmark Underperformance Dashboard Metrics Example

Your response:

This question has not been answered yet.

There is no one right answer for this question. When looking for areas to improve within a care setting it is important to consider factors such as:

• The severity of the issue.
• The number of patients affected.
• Any financial impacts.
• Stakeholders involved.
• Measureable outcomes.
• Benchmark Underperformance Dashboard Metrics Example

By building an objective, evidence-based case around these considerations, in addition to any legal or regulatory factors, it is possible to reach a good decision about improvement projects to pursue.

Benchmark Underperformance Dashboard Metrics Example Conclusion

In this activity, you had the opportunity to review various dashboards and other reports in order to evaluate Mercy Medical Center’s performance against local, state, and federal requirements. Use the information you acquired here as well as external research into appropriate standards to complete your course assignment. Benchmark Underperformance Dashboard Metrics Example

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Solution: