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NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Student Name

Capella University

NHS-FPX 6004 Health Care Law and Policy

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Dashboard Metrics Evaluation 

Performance dashboards are essential indicators for healthcare organizations to monitor and evaluate the quality of their services so that effective improvements can be ensured. One such dashboard is evaluated in this assessment for Mercy Medical Center (MMC). The dashboard metrics are for diabetes screening tests, evaluated against the Agency for Healthcare Research and Quality (AHRQ) benchmarks. Based on the evaluation, an ethical and sustainable action plan is developed to improve the quality of care and address the shortcomings. 

Dashboard Metrics Evaluation Against National Benchmarks

For the background, Mercy Medical Center is one of the top healthcare choices for people around Shakopee, Minnesota. The organization has received many awards for safe surgery, outstanding patient experiences, being one of the top 20 workplaces, and being the best hospital for emergency care. These awards and recognition in the healthcare industry oblige MMC to continue providing quality healthcare services and addressing underperformances. However, MMC’s performance dashboard has shown some lack of diabetic screening tests. AHRQ’s benchmarks play an important role in evaluating the dashboard as they are the standards, and healthcare organizations must meet the standards to maintain quality and reputation in the industry.

Data has been collected for three metrics: eye tests, foot examinations, and HBA1c laboratory testing. While the national benchmark for eye exams is 75.2%, MMC had 35.5% tests in 2019 and 41% in 2020. Similarly, the national benchmark for foot exams is 84%, significantly higher than the MMC’s data, at 40-42%. Lastly, only 37% and 48% of HBA1c tests were conducted in 2019 and 2020 at MMC, whereas the national benchmark lies at 79.5% and instructs to get HBA1c levels checked twice a year (Agency for Healthcare Research and Quality, n.d.; Capella University, n.d.).

The evaluation reveals MMC’s underperformance in all of the diabetes screening tests as compared to the national benchmarks. Since Diabetes is a chronic disease, ensuring patients receive adequate testing to prevent complications and enhance their quality of life is advocated. Thus, organizations must take immediate action to address the shortfalls. Some of the knowledge gaps in this evaluation are related to the frequency of the tests, gender and race-based underperformances to identify the root-cause factors and MMC’s existing approach to tackling the situation. When addressed, these knowledge gaps will help develop organization-centered and effective strategies. 

Consequences of Underperforming the Benchmarks 

As stated earlier, Diabetes is a chronic healthcare condition that may lead to several complications if it remains undiagnosed or untreated for a longer time. Recently, the prevalence of Diabetes and diabetic complications has been rocketing high, consequently burdening individuals and the healthcare system (Mao et al., 2019). Not meeting diabetes screening benchmarks can lead to delayed diagnosis, increased healthcare risks, and high treatment costs for the patients. Delayed diagnosis can result in missed opportunities, leading to several complications. For example, delaying eye examinations for diabetic patients can lead to diabetic retinopathy, eventually causing blindness. Similarly, a lack of foot exams may cause diabetic foot ulcers and, ultimately, amputation of the leg.

Thus, screening tests are essential for the early detection of complications so that effective interventions can be planned and implemented promptly (Peer et al., 2020). Secondly, without timely screening and diagnosis, individuals may continue to live with undiagnosed Diabetes or diabetic complications, exposing them to various health risks, such as heart diseases, kidney problems, neuropathy (nerve issues), and vision issues (retinopathy). These complications can significantly impact patients’ quality of life. Such complications often require more intensive medical intervention and costly medications, increasing healthcare expenses for individuals and the healthcare system. Therefore, screening tests are essential as this comprehensive primary care will prevent patients from emergencies and hospital admissions (Kaur et al., 2022). 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

On the other hand, this underperformance may have several implications for healthcare organizations and teams. Since the mission of MMC is to provide quality and preventive care to its consumers, underperformance may hinder the accomplishment of the mission. Ultimately, the patient population in MMC may consider the organisation unable to provide preventive care, consequently, patients’ trust will be eroded, and the organization may face limited patient influx. Secondly, the underperformance may increase the prevalence of diabetes and its complications, which in turn, can incur the overall healthcare costs for the organization, adding strain on healthcare resources, such as logistics (hospital beds and space), healthcare providers, and equipment (Mao et al., 2019). 

The challenges causing underperformance are a need for more availability of resources and a lack of awareness among the patient population. It is assumed in the analysis that screening diabetes complications is essential to prevent the growing prevalence of the disease. Another assumption is to accessibility of healthcare services. This must be ensured by expanding facilities and meeting financial constraints. Lastly, the assumption is that patients must be aware and encouraged to participate in their healthcare process. 

Evaluation of an Underperformed Benchmark – Eye Examinations

The benchmark underperformance evaluation revealed that eye examination has about a 35-40% shortfall from the national benchmark. Thus, this report plans to evaluate eye examinations as crucial tests for diabetics. Expanding eye examination rates can significantly improve the overall quality of care and organizational performance. Diabetic retinopathy is a common complication of Diabetes. According to Zegeye et al. (20223), the prevalence of diabetic retinopathy is approximately 27.0%, which results in 0.4 million cases of blindness worldwide.

This complication affects the blood vessels in the retina, leading to vision impairment or blindness in later stages. Such complication not only diminishes individuals’ quality of life but also imposes a burden on the community in terms of increased healthcare costs and the need for additional support services for those with vision impairment. Regular eye examinations in diabetic patients can assist in the early detection of the complication (Kropp et al., 2023). This can improve the quality of care provided by the MMC and the interprofessional team as they can timely initiate interventions to prevent the progression of the condition and the cascading effects of vision loss and promote the overall well-being and productivity of the community.

Incorporating eye examination and addressing the underperformed benchmark can lead to holistic and patient-centered care (Pardhan et al., 2023). This way, the organization will demonstrate its efforts for effective diabetes management and the well-being of individual patients and community members. Patients will adhere to recommended treatments and screenings, perceiving a comprehensive approach to their care.

Ethical and Sustainable Actions to Address the Underperformed Benchmarks

To effectively tackle the underperformance in eye examination, MMC should undertake several ethical and sustainable actions to improve the quality of care and the organization’s performance. The group of stakeholders that will act on improving the benchmark metric are clinical staff (eye specialists, optometrists, nurses), the administrative team, the quality improvement and compliance monitoring team, and patients and their families. Clinical staff should take action as it is within their role description to provide eye exams and comprehensive care to the patients. Administrators should take action because they can ensure they manage and make necessary resources available within the organization.

They will also ensure the efficient scheduling of appointments and develop policies within the organization. Simultaneously, the quality improvement team should take action because it is their responsibility to ensure that the organization complies with benchmarks and is committed to patient safety and well-being. Lastly, patients and their families are essential to this plan, as their actions and involvement are necessary to ensure the plan is adequately accomplished. Their adherence to self-management and screening appointments is crucial for improving benchmark underperformance. 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

The ethical and sustainable actions that can be initiated to address the benchmark shortfalls are: 

  1. Patient Education: A study by Mohammad et al. (2021) showed that the awareness of regular eye examination is significantly lower in patients regardless of the high prevalence of retinal problems. Following the ethical principle of autonomy and informed decision-making, it is imperative to provide patients with adequate education and knowledge about the importance of eye examinations, including the potential consequences of not getting screened, and empower them to make informed choices about their health. 
  2. Adequate Resource Allocation: Adequate resources are necessary to perform such tests. The stakeholders’ primary responsibility is to allocate resources appropriately, including necessary equipment and human resources. This is to ensure that eye examinations can be conducted promptly and efficiently. This action is based on the ethical principles of justice and fairness. 
  3. Staff Education: Under the ethical principle of beneficence, it is essential to provide continuous training to healthcare staff to stay updated on the cutting-edge developments in diabetes-related eye health, ensuring that patients receive the topmost standard of care and are benefiting from the healthcare developments (Lima et al., 2019).


AHRQ. (n.d.). National Healthcare Quality and Disparities Reports (NHQDR). NHQDR Data Tools | AHRQ Data Tools. https://datatools.ahrq.gov/nhqdr?count=2&tab=nhqdrnabe&type=subtab 

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

Kaur, G., Chauhan, A. S., Prinja, S., Teerawattananon, Y., Muniyandi, M., Rastogi, A., Jyani, G., Nagarajan, K., Lakshmi, P., Gupta, A., Selvam, J. M., Bhansali, A., & Jain, S. (2022). Cost-effectiveness of population-based screening for Diabetes and hypertension in India: An economic modelling study. The Lancet Public Health7(1), e65–e73. https://doi.org/10.1016/S2468-2667(21)00199-7 

Kropp, M., Golubnitschaja, O., Mazurakova, A., Koklesova, L., Sargheini, N., Vo, T.-T. K. S., 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 Journal14(1), 21–42. https://doi.org/10.1007/s13167-023-00314-8 

Lima, G. C. D. B. B., Guimarães, A. M. D., Silva, J. R. S., Otero, L. M., & Gois, C. F. L. (2019). Health education and methodological devices applied in the care of Diabetes Mellitus. Saúde em Debate43, 150-158.  https://doi.org/10.1016/JCPSP.558561.

Mao, W., Yip, C.-M. W., & Chen, W. (2019). Complications of Diabetes in China: Health system and economic implications. BMC Public Health19(1), 269. https://doi.org/10.1186/s12889-019-6569-8 

Mohammad, A. A. A., Alqaraghuli, H. A., & Mahdi, H. A. (2021). Awareness for need of regular eye exams and retinal involvement in diabetes patients. Archivos Venezolanos de Farmacología y Terapéutica40(2), 192–196. https://www.redalyc.org/journal/559/55969713014/html/ 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Pardhan, S., Upadhyaya, T., Smith, L., Sharma, T., Tuladhar, S., Adhikari, B., Kidd, J., & Sapkota, R. (2023). Individual patient-centered target-driven intervention to improve clinical outcomes of Diabetes, health literacy, and self-care practices in Nepal: A randomized controlled trial. Frontiers in Endocrinology14https://www.frontiersin.org/articles/10.3389/fendo.2023.1076253 

Peer, N., Balakrishna, Y., & Durao, S. (2020). Screening for type 2 diabetes mellitus. The Cochrane Database of Systematic Reviews2020(5), CD005266. https://doi.org/10.1002/14651858.CD005266.pub2 

Zegeye, A. F., Temachu, Y. Z., & Mekonnen, C. K. (2023). Prevalence and factors associated with Diabetes retinopathy among type 2 diabetic patients at Northwest Amhara Comprehensive Specialized Hospitals, Northwest Ethiopia 2021. BMC Ophthalmology23(1), 9. https://doi.org/10.1186/s12886-022-02746-8 

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