Write a 3-5 page report for a senior leader that communicates your

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.
mpleting this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
RUBRIC
- 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.

Healthcare Law and Policy Dashboard Metrics Evaluation

Student Name

University Name

Course Name: Course Title

Instructor Name

Date

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Healthcare Law and Policy Dashboard Metrics Evaluation

Benchmarking involves evaluating the organization’s products or performance-based

the specific needs. Organizations use benchmarking to enhance their performance value.

Value in healthcare is measured by the outcomes and not the quantity of care delivered

(Willmington et al., 2022). The primary objective of healthcare providers includes delivering

quality care to improve patient outcomes. Notably, healthcare organizations utilize

benchmarks to analyze internal healthcare delivery data and comparing with local and

international data. Moreover, benchmarking in healthcare organizations includes evaluating

the organization’s internal processes to build the foundation for quality healthcare delivery.

This paper will use Mercy Medical Center to demonstrate benchmark evaluation.

Dashboard Metrics Evaluation for Mercy Medical Center

Mercy Medical Center (MMC) is among the top healthcare organizations that deliver

quality care to patients, including children, adults, and the elderly. MMC was ranked the top

organization for delivering safe and effective surgery (Mdmercy.com, n.d.). The MMC chief

finance officer has evaluated the public health dashboard for diabetes and the fact sheet from

the quality assurance department (Mdmercy.com, n.d.). Thus, the information presented

would be essential in identifying underperforming metrics and comparing them with state and

local government laws and policies. The organization’s leadership will also identify

shortcomings and develop strategies to collaborate with staff to promote quality

improvement.

The public health dashboard for diabetes during the last quarter of 2020 reports an

increase in the number of diabetic patients across all races, ages, and gender. According to

race metrics, there were 350 whites, 75 Indian Americans, 18 African Americans, and 13

individuals from other minority groups (Villa Health, n.d.). Gender metrics report 213 male

and 346 female patients (Villa Health, n.d.). There were 117 patients aged 20 and below, 50

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patients aged 21 to 44, 6100 patients aged 45 to 64, and 2372 patients aged 65 and above

(Villa Health, n.d.). MMC serves a culturally diverse patient population, including 28,530

whites, 3822 Asians, 2890 Hispanic-Latino, 1601 African Americans, 430 Indian Americans,

and 11660 other minority groups (Villa Health, n.d.).

Benchmarks Set by Local, State, or Federal Healthcare Policies

Helminski et al. (2022) mentioned that dashboards are used to document critical care

assessment, trends, and patterns. They also identify care quality concerns and issues related to

staffing and other factors affecting healthcare delivery. Mercy Medical Center uses

benchmarks to analyze patient safety, readmission, medication errors, and demographic

factors affecting healthcare delivery. The organization has developed metrics that are used to

meet benchmark standards. For example, Mercy Medical Center developed benchmarks to

identify the local and international chronic obstructive pulmonary disease (COPD), heart

failure, and pneumonia rates. The organization also uses benchmarks to evaluate patient fall

rates, patient injuries, pressure scores, and patient information documentation errors within

the organization. It is worth noting that local governments utilize quality collaboration where

the community health departments collect public health data and compare the performance

(Agarwal et al., 2019). The Agency for Healthcare Research and Quality (AHRQ) identifies

benchmark sources at the federal level, including national quality assurance organizations,

health information technology systems, and health administration and data systems.

The national healthcare quality and disparities report (NHQDR) evaluate states’

performance in diabetes care quality. Thus, NHQDR identifies benchmarks for each state,

including 80% of diabetic patients for annual eye or foot exams (Ahrq.gov, 2019).

Specifically, the annual foot exam should be 85% and the eye exam should be 75.2

(Ahrq.gov, 2019). According to MMC dashboard metrics, areas of interest include the low

HgbA1c test and foot exam (Villa Health, n.d.). Still, the HgbA1c test and foot exam are

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useful in determining potential health complications related to diabetes. 18 African

Americans were identified as new patients in the last quarter in MMC, and the number of

Hispanics was not identified. According to the Centers for Disease Control and Prevention,

there is a high prevalence of diabetes among African Americans than whites (CDC, 2020).

The patient fall rate in the United States hospital is about 6 falls in 1000 bed days

(Heng et al., 2020). Heng et al. (2020) added that factors contributing to patient fall in US

hospitals include incomplete assessment, a lack of adherence to patient safety protocols, poor

communication structure, a lack of effective leadership, and inadequate staff training on

patient safety protocols. MMC scored 120 in quality leadership and staffing and 100 in

nursing skills and competence (Villa Health, n.d.). It also scored 100 in the ICU physicians’

skills (Villa Health, n.d.).

Consequences of Not Meeting Prescribed Benchmarks and Impacts It Has on

Healthcare Organization

Inadequate staffing is the most significant barrier to meeting the prescribed

benchmarks. Thus, MMC faces challenges, such as inadequate staffing and a lack of

diversity. Another challenges that MMC faces include medication errors which increased

from 4 to 8 in the last quarter. Factors contributing to medication errors include inadequate

staffing and a high workload. Thus, a lack of prescribed benchmarks in MMC would

negatively impact patient outcomes. Not meeting prescribed benchmarks means a healthcare

organization would not identify areas of quality improvement. In this case, MMC lacks

cultural diversity, which is crucial for meeting prescribed benchmarks since many healthcare

organizations and local and state public health leverage cultural diversity to ensure quality

improvement. Nair and Adetayo (2019) maintained that a lack of cultural diversity is a

significant challenge for attaining care quality standards because of communication barriers.

Evaluating Underperforming Benchmark

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MMC reported issues of interest through the public health dashboard for diabetes.

These areas included reducing HgbA1c tests and foot exams (Villa Health, n.d.). The number

of eye exams in MMC has declined in the last quarter, which can affect the overall health

outcomes of diabetic patients (Villa Health, n.d.). Moreover, MMC experienced high patient

falls based on the national patient fall rates. Foot exam in MMC was low based on the public

health diabetes dashboard, which should be at least 84% according to the NHQDR. The

benchmarks affect staff and patients, but declining Hgb1Ac tests and foot exams significantly

affect patient outcomes. A lack of diversity in healthcare undermines the patient’s health and

trust. Therefore, MMC must establish healthcare delivery standards that will streamline the

performance across all levels, including departments and nursing units. It is essential to

achieve a high patient flow and improve patient healthcare outcomes and experience.

Various underperformances have been addressed by introducing programs that would

enhance healthcare delivery and ensure culturally competent and patient-centered quality

care. Departments that appear not to meet prescribed benchmarks include medical and

surgery, bariatric services, and orthopedics. On that note, these departments are faced with

inadequate nurse staffing. The nursing shortage is associated with increased medication errors

and higher morbidity and mortality rates. These factors are associated with the lower

benchmarks in these departments. It is worth mentioning that MMC must identify or develop

strategies for addressing the high rate of patient falls to meet the prescribed benchmarks.

Ethical and Sustainable Actions

MMC must develop quality improvement strategies to improve underperforming

benchmarks. Still, the organization must identify ethical implications and sustainable actions.

Staff and stakeholders must collaborate to realize quality improvement. For example,

collaboration is critical to addressing medication errors due to inadequate staffing. Quality

improvement initiatives contribute to quality healthcare delivery, but how it also influences

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patient care raises ethical considerations regarding respect, justice, and dignity (Hunt et al.,

2021). Promoting diversity in healthcare can also raise ethical implications, such as autonomy

and respect. For instance, MMC must expand its marketing to promote cultural diversity.

Expanding marketing includes advertising quality and safe healthcare delivery, which can

lead to the disclosure of patient health information. MMC also faces high patient

readmission, which can be avoided by reducing medication errors and encouraging

collaboration among stakeholders and healthcare professionals. MMC should also prioritize

fall prevention by following patient safety protocols. The healthcare organization should

identify fall prevention programs across all departments to achieve universal results. Nurse

leaders must develop the cultural competence to encourage patients to promote privacy and

confidentiality of patient health information when developing and implementing strategies for

addressing underperforming benchmarks.

Conclusion

Benchmark is fundamental to evaluating a healthcare organization’s quality healthcare

delivery standards. Mercy Medical Center’s public health dashboard metrics have been

evaluated throughout this paper. The public health dashboard metrics were evaluated by

comparing them with the local, state, and federal levels. Thus, MMC has utilized public

health dashboard metrics to areas of concern and develop quality improvement strategies.

Areas of concern identified included patient falls, medication errors, readmission, inadequate

staffing, and a lack of cultural diversity. Departments that do not meet prescribed benchmarks

included medical and surgery, bariatric services, and orthopedics.

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References

Agarwal, S., Sripad, P., Johnson, C., Kirk, K., Bellows, B., Ana, J., Blaser, V., Kumar, M. B.,

Buchholz, K., Casseus, A., Chen, N., Dini, H. S. F., Deussom, R. H., Jacobstein, D.,

Kintu, R., Kureshy, N., Meoli, L., Otiso, L., Pakenham-Walsh, N., & Zambruni, J. P.

(2019). A conceptual framework for measuring community health workforce

performance within primary health care systems. Human Resources for Health, 17(1).

https://doi.org/10.1186/s12960-019-0422-0

Ahrq.gov. (2019). National Healthcare Quality and Disparities Reports | Agency for

Healthcare Research & Quality.

https://www.ahrq.gov/research/findings/nhqrdr/index.html

CDC. (2020, August 7). CDC. Prevalence of Diagnosed Diabetes.

https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-diabetes.html

Helminski, D., Kurlander, J. E., Renji, A. D., Sussman, J. B., Pfeiffer, P. N., Conte, M. L.,

Gadabu, O. J., Kokaly, A. N., Goldberg, R., Ranusch, A., Damschroder, L. J., &

Landis-Lewis, Z. (2022). Dashboards in health care settings: Protocol for a scoping

review. JMIR Research Protocols, 11(3), e34894. https://doi.org/10.2196/34894

Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A.-M., & Morris, M. E. (2020). Hospital

falls prevention with patient education: A scoping review. BMC Geriatrics, 20(1).

https://doi.org/10.1186/s12877-020-01515-w

Hunt, D. F., Dunn, M., Harrison, G., & Bailey, J. (2021). Ethical considerations in quality

improvement: key questions and a practical guide. BMJ Open Quality, 10(3),

e001497. https://doi.org/10.1136/bmjoq-2021-001497

Mdmercy.com. (n.d.). Mercy Medical Center Recognized among Best Hospitals in the Nation

– Mercy – Baltimore, Maryland. Retrieved October 27, 2022, from

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https://mdmercy.com/about-mercy/news-and-media/news/2020/february/mercy-

medical-center-recognized-among-best-hospitals-in-the-nation

Nair, L., & Adetayo, O. A. (2019). Cultural competence and ethnic diversity in healthcare.

Plastic and Reconstructive Surgery – Global Open, 7(5).

https://doi.org/10.1097/gox.0000000000002219

Vila Health. (n.d.). Dashboard and Health Care Benchmark Evaluation. Capella University.

https://media.capella.edu/coursemedia/nhs6004element17010/wrapper.asp#

Willmington, C., Belardi, P., Murante, A. M., & Vainieri, M. (2022). The contribution of

benchmarking to quality improvement in healthcare. A systematic literature review.

BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07467-8

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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.

Introduction

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.

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.

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.

1. 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.

1. 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 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.

8. Which metrics are not meeting the benchmark for the organization?

8. What are the local, state, or federal health care policies or laws that establish these benchmarks?

8. What conclusions can you draw from your evaluation?

8. 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.

9. Consider the following examples:

1. Organizational mission and vision.

1. Resources.

2. Staffing.

2. FinancialOperational and capital funding.

2. Logistical considerations: Physical space.

2. Support services (any ancillary department that gives support to a specific care unit in the organization, such as pharmacy, cleaning services, dietary, et cetera).

1. Cultural diversity in the community.

1. Staff skills.

1. Procedures and processes.

9. Address the following:

2. What are the challenges that may potentially contribute to benchmark underperformance?

2. 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.

10. Focus on the benchmark you chose to target for improvement. Which metric is underperforming its benchmark by the greatest degree?

10. State the benchmark underperformance that is the most widespread throughout the organization or interprofessional team.

10. State the benchmark that affects the greatest number of patients.

10. Include how this underperformance will affect the community that the organization serves.

10. 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.

11. Who would be an appropriate group of stakeholders to act on improving your identified benchmark metric?

11. Why should the stakeholder group take action?

11. What are some ethical actions the stakeholder group could take that support improved benchmark performance?

· Organize content so ideas flow logically with smooth transitions.

12. 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.

13. Be sure to apply correct APA formatting to source citations and references.

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:

14. A title and references page. An abstract is not required.

14. 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.

Portfolio Prompt: You may choose to save your report to your
ePortfolio.

Competencies Measured

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.

16. 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.

17. 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.

Dashboard Benchmark Evaluation

Brittany Leese

Capella University

Health Care Law and Policy

May 2022

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Dashboard Benchmark Evaluation

Healthcare organizations all over the world are using quality dashboards more frequently

to monitor the quality of care being provided (Randall et al., 2020). The use of dashboards allows

for organizations to evaluate their performance in various areas of one medical intervention,

diagnosis, or patient population. There are benchmarks often set by federal, state, or local laws

and policies that establish the appropriate care needed for specific populations and diagnoses. In

this assessment, the focus is on the eye examinations and foot examinations in the diabetic

population at Mercy Medical Center in Minnesota and assessing the changes necessary to met

benchmark goals.

Evaluation of Dashboard Metrics

The Mercy Medical Center’s dashboard for their diabetic patient populations evaluates

the percentage of foot exams, eye exams and HgbA1c testing completed during the years 2019

and 2020. The HgbA1c testing was fairly consistent with a drop in performance for quarter two

and four of year 2019. The eye exam dashboard showed a significant decrease in quarter four of

2019 and quarter two of 2020, while the remainder of the dashboard remained consistent. The

percentage of foot exams completed during quarter three of 2019 and quarter two and three of

2020 showed decline in completion. While there is no consistent pattern amongst the three areas

examined, the sudden decrease across the three areas examined, determines there is a need for

improvement to create more consistency of evaluations completed in the diabetic patient

population.

Diabetes affects approximately 8.8 percent or 390,000 adults in the state of Minnesota

alone (Diabetes in Minnesota – Minnesota Department of Health, 2022). The national

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benchmarks for foot examinations on diabetic patients over the age of forty on an annual basis is

84 percent (NHQDR Web Site – National Diabetes Benchmark Details, n.d.). The benchmark set

for the same diabetic adult population in regards to receiving a dilated eye examination annually

is 75.2 percent (NHQDR Web Site – National Diabetes Benchmark Details, n.d.). There is also a

national standard established for measuring HgbAlc levels twice annually and that is 79.5

percent of the diabetic population (NHQDR Web Site – National Diabetes Benchmark Details,

n.d.). These benchmarks were created by the National Healthcare Quality and Disparities Report

by examining the above mentioned across the United States to determine the quality measures

and what the standard should be.

Based on what is found in the dashboard for Mercy Medical Center, national benchmarks

are not being achieved and there is a need for improvement for the care of the diabetic

population in which it serves. The evaluation of HgbAlc levels helps determine glycemic control

over a period of time, instead of a daily log. The purpose of having good glycemic control and

the reason it is important to examine twice yearly is to help prevent the complications that can

occur from uncontrolled glucose levels (Tommerdahl et al., 2021). The leading cause of

blindness in adults from ages 18 to 64, is due to diabetes (cite). Research shows that a lack of

glycemic control increased the risk of retinopathy and other eye related conditions, which places

an emphasis of why annual eye exams should be completed (Tommerdahl et al., 2021). The

microvascular damage that occurs from uncontrolled glucose levels can lead to neuropathy in the

feet. This places the patients at risk for diabetic foot wounds, which can lead to infection and

amputation and also adds to increased healthcare costs (Tommerdahl et al., 2021). Ensuring that

HgbAlc levels and both eye and foot examinations are evaluated routinely will aid in prevention

of the mentioned diabetic complications.

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There is concern that the lack of insurance coverage that could have influenced lack of

meeting benchmarks for Mercy Medical Center. With the implementation of the Affordable Care

Act, it was found that not only did the number of those diagnosed with diabetes increased, but so

did the compliance with preventative services (Marino et al., 2020). There was also noted to

more compliance to diabetic medications that aided in a decreased HgbAlc level overall (Marino

et al., 2020). The goal of the Affordable Care Act was to allow for increased access to healthcare

overall and there may still be diabetic patients that either do not qualify or are unaware of the

assistance available to them to have the medical insurance coverage needed to manage their

diabetes.

Challenges Posed by Meeting Benchmarks

When national benchmarks are established, despite efforts to look at the nation as a

whole, it can tend to overlook specific populations or challenges that can prevent organizations

from being considered successful. Often when organizations establish a dashboard to compare

their practices, it is based off of another organization, which may or may not be similar, or care

for a similar population of people. There are many variables that can influence the success of

meeting benchmarks, such as: patient race, insurance coverage, language barriers, financial

status and level of education (Diabetes in Minnesota – Minnesota Department of Health, 2022).

These can influence the patient’s compliance or abilities to be compliant with preventative exams

as they may not be able to comprehend the importance of them or financially be able to comply.

From an organizational standpoint, areas that could influence their ability to meet benchmarks

could be medical provider availability and an understanding of the population in which they

serve. To best address this, it is imperative that there are enough providers available, that

understand the importance of preventative examinations, to treat the volume of diabetics that

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seek care at the Mercy Medical Center and that they are versed on the challenges that are posed

by the patient population. When an organization is setting their own benchmarks, they should be

considering the population they serve and national benchmarks. The data collected by doing this,

allows for the organization itself to self-evaluate their successes and shortcomings and allows

them to adjust their services and resources to meet the need of the community in which is serves.

Improving Performance

The dashboard for Mercy Medical Center showed a significant decrease in various

quarters in both eye and foot examinations. While both areas are significant to address, the foot

examinations are a priority. The completion of foot examinations is at an average of 58 percent

for the years 2019 and 2020 at Mercy Medical Center, the national benchmark is 84 percent. One

in three people diagnosed with diabetes will experience a foot wound during their lifetime

(Phillips & Edmonds, 2021). These wounds increase the patient’s risk of the spread of infection

to the blood, otherwise known as sepsis, which can be life-threatening. There is also delayed

wound healing with diabetic patients, which often leads to amputations of limbs. With the risk of

losing life or limb, it is imperative that foot examinations are completed on every diabetic patient

at every encounter. Due to preventative examinations occurring once or twice a year, it is also

important to educate the patient of examining their own feet for any wounds on a daily basis and

knowing when to contact their primary care provider for a more thorough examination (Phillips

& Edmonds, 2021). In order to meet benchmarks, it is imperative that each time a diabetic

patient is seen in the office, enough time is allotted to allow for a proper foot exam to occur.

There should also be discussion with the patient who may not be agreeable to the exam, in a

manner of which they can understand, the importance of a foot exam being completed as it can

prevent diabetic complications.

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Advocate for Ethical Action

The noted deficit in the regards to the benchmark of foot examinations can lead to serious

diabetic complications that can affect the patient’s ability to function in everyday life, or worse,

cause them to lose their life. It is imperative that the medical providers at Mercy Medical Center

are provided further education on diabetic foot wounds and proper examination. It is important

that the providers understand the importance, as they are often the one who is providing the

patient education on caring for themselves at home. It is highly recommended that the patient,

family member, or caregiver be given guidance and resources on what to look for when

examining their feet at home (Phillips & Edmonds, 2021). This allows the patient also feel

included in their care and will help to prevent potential poor outcomes. The issue of non-

compliance with diabetic medications and other treatment plans can lead to the patient not

receiving the same care as a compliant patient would, it is necessary that every patient,

regardless of compliance is provided with a foot exam during their preventative care visit, as this

is an ethical duty of the medical provider. With treating each patient with the care they deserve, it

will improve the relationship with the provider and can potentially increase compliance with

other treatments. This will aid in improving Mercy Medical Center’s ability to meet the national

benchmarks for foot examinations in the diabetic population in which they serve.

Conclusion

National benchmarks are established to create a standard of care expected to be provided

to a certain population. Mercy Medical Center was found to not be meeting benchmark

expectations in regards to the care of their diabetic patients, especially in regards to foot

examinations. To improve this benchmark, it is going to require a collaborative effort amongst

the medical team and the diabetic population that are served at Mercy Medical Center. Due to the

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potential loss of life or limb if a foot wound is left untreated, it is important that the medical

providers at Mercy Medical Center are educated on the significance of completing a foot exam

during preventative care visits. It is also important that despite non-compliance or challenging

patients, each patient is deserving of the same treatment and education on how to examine their

feet at home.

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References

Diabetes in minnesota – minnesota department of health. (2022, February). Minnesota

Department of Health. Retrieved May 28, 2022, from

https://www.health.state.mn.us/diseases/diabetes/data/diabetesfacts.html

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

NHQDR web site – national diabetes benchmark details. (n.d.). Agency for Healthcare Research

and Quality. Retrieved May 28, 2022, from

https://nhqrnet.ahrq.gov/inhqrdr/National/benchmark/table/Diseases_and_Conditions/Dia

betes

Phillips, A., & Edmonds, M. (2021). ACT NOW in diabetes and foot assessments: An essential

service. British Journal of Community Nursing, 26(3), 116–120.

https://doi.org/10.12968/bjcn.2021.26.3.116

Randall, R., Alvarado, N., Mcvey, L., Ruddle, R., & Doherty, P. (2020). Requirements for a

quality dashboard: Lessons from national clinical audits. AMIA Annual Symposium

Proceedings Archive, 735–744.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7153077/pdf/3202960.pdf

Tommerdahl, K. L., Shapiro, A. L. B., Nehus, E. J., & Bjornstad, P. (2021). Early microvascular

complications in type 1 and type 2 diabetes: Recent developments and updates. Pediatric

Nephrology, 37(1), 79–93. https://doi.org/10.1007/s00467-021-05050-7

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