NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

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

Mercy Medical Center’s (MMC) diabetes care dashboard reveals critical areas of underperformance, particularly in HgbA1c exams, foot exams, and eye exams. Inconsistent and declining metrics in these areas highlight significant gaps in diabetes management and adherence to local, state, and federal benchmarks. The impact of these deficiencies extends beyond patient outcomes, affecting MMC’s reputation, resource allocation, and staffing efficiency. Addressing these issues requires a coordinated, ethical approach involving diverse stakeholders to improve care quality, ensure equitable access, and implement sustainable practices.

Evaluate Dashboard – Underperforming Metrics

 MMC diabetes dashboard provides a comprehensive overview of their performance against various benchmarks set forth by local, state, and federal health care policies. Analyzing this data reveals areas where the organization excels and areas where improvement is necessary to meet these benchmarks. Notably, the metrics for HgbA1c exams and foot exams could be performing better. HgbA1c exams, crucial for monitoring long-term blood glucose control in diabetic patients, have shown inconsistent and generally declining numbers. For instance, the number of HgbA1c exams was 60 in Q1 2019 but fluctuated and reached only 64 by Q4 2020. Similarly, foot exams, which are vital for preventing diabetic foot complications, are underperforming. Despite a peak of 75 in Q1 2020, the numbers dipped to 48 in Q3 2020 and only slightly improved to 62 by Q4 2020. These fluctuations indicate a need for consistent adherence to the recommended screening protocols. Eye exams, a critical metric for diabetic patients due to retinopathy risk, fluctuated: 50 in Q1 2019, 42 in Q4 2019, and 64 by Q4 2020. These variations indicate potential gaps in monitoring and follow-up, risking undiagnosed complications (NHDQR, 2022).

Local, state, and federal policies stress regular screenings and preventative care for managing diabetes, with the Centers for Medicare & Medicaid Services (CMS) setting benchmarks for quality care. Diabetic patients should have at least two HgbA1c tests per year if stable and annual foot and eye exams (Kollipara et al., 2021). The declining and inconsistent numbers at MMC indicate that these benchmarks need to be consistently met, highlighting a significant area for improvement. The evaluation shows MMC needs to stabilize and increase the frequency of HgbA1c, foot, and eye exams to meet health care benchmarks. Inconsistent performance could lead to undiagnosed complications and poorer outcomes, impacting overall care quality. Addressing these issues could improve patient outcomes, enhance compliance with healthcare laws, and boost patient satisfaction and trust. Several unknowns and areas of uncertainty affect the evaluation’s completeness for MMC. The dashboard needs to include data on the total number of new patients per quarter, making it hard to identify trends. There is also no comparative data from similar facilities for accurate benchmarking and no detailed demographic data on patients, which could reveal disparities in care. Enhancing data availability, including detailed demographics, comparative benchmarks, and historical patient data, would improve the evaluation process for MMC.

Consequences of Not Meeting Prescribed Benchmarks

MMC’s failure to meet benchmarks for HgbA1c, foot, and eye exams has significant impacts, compromising its mission for high-quality care and vision of excellence. This deficit risks diminishing MMC’s reputation and its standing in consumer awards and other recognitions. Allocation of resources is heavily impacted by benchmark underperformance, as inefficiencies in diabetes care require additional investments, straining financial resources. This misalignment may lead to increased budgetary expenditures and affect overall efficiency (Sin et al., 2020). Inadequate performance also influences staffing needs, as the organization may require hiring additional specialized staff, such as diabetes educators or care coordinators, and increasing workloads for existing staff. This may lead to exhaustion and decreased morale, affecting the quality of care (Alshammari et al., 2021). Financially, not meeting benchmarks leads to increased operational costs from complications like readmissions and emergency interventions. Underperformance can also affect eligibility for federal financial incentives tied to performance metrics. This may result in reduced operational and capital funding, impacting MMC’s overall financial stability.  Logistically, the need for additional resources or expanded facilities can strain existing space and disrupt operational efficiency. Increased demand for support services, like pharmacy and dietary, due to underperformance can lead to delays and reduced quality, affecting patient care (Garcia et al., 2022).  

Cultural competency is critical as MMC serves a diverse community, and benchmark underperformance may exacerbate health disparities in certain demographic groups. Tailoring care to meet cultural and linguistic needs is essential for effective diabetes management and equitable care delivery (Joo & Liu, 2020). Staff skills and training are crucial, as benchmark underperformance may reveal gaps in staff preparedness for exams or managing diabetic patients. Investing in comprehensive training is vital for improving care quality and achieving benchmark compliance (Kime et al., 2020). Procedural and process inefficiencies, such as irregular exam scheduling and lack of standardized follow-up protocols, contribute to benchmark underperformance. Revising and standardizing these procedures is essential for consistent performance and improved care quality. Challenges contributing to benchmark deficits include inadequate patient follow-up systems, insufficient staff training, resource constraints, and logistical issues. Cultural and language barriers may also impact patient adherence to care protocols (Kvarnström et al., 2021). The analysis assumes benchmarks accurately indicate care standards and that the dashboard data reflects performance. It also presumes addressing gaps in resources, staffing, and procedures will improve performance and compliance.

Evaluating a Key Benchmark Underperformance

Among the metrics for diabetes management at Mercy Medical Center (MMC), HgbA1c exam underperformance presents the most critical opportunity for improving quality and performance. Irregular and declining numbers, fluctuating from 60 in Q1 2019 to 64 by Q4 2020, reflect a troubling inconsistency undermining effective diabetes management. This issue is the most widespread throughout MMC’s diabetes care system. While foot and eye exams also show variability, the HgbA1c metric stands out due to its central role in long-term diabetes management and its broader implications for patient care. Inconsistent HgbA1c testing directly impacts a large portion of the diabetic population, leading to inadequate disease monitoring and potentially severe health complications (Boye et al., 2022).

The underperformance in HgbA1c exams has significant repercussions for the community served by MMC. Uncontrolled diabetes, due to infrequent or irregular HgbA1c/ HbA1c testing, can result in an increased incidence of complications such as cardiovascular disease, neuropathy, and nephropathy. These complications not only deteriorate patients’ quality of life but also escalate medical costs and place additional strain on local healthcare resources (Khor et al., 2023). Consequently, addressing this benchmark shortfall is crucial for mitigating these adverse outcomes and improving community health. Focusing on enhancing HgbA1c exam performance offers the most incredible opportunity to elevate MMC’s overall quality of care. By stabilizing and increasing the frequency of HgbA1c testing, MMC can enhance its diabetes management practices, leading to earlier detection of complications, better disease control, and ultimately improved patient outcomes (Chen et al., 2023). This improvement will align MMC with established benchmarks and reinforce its commitment to high-quality care and patient satisfaction.

Advocating for Ethical and Sustainable Actions

To address the underperformance in HgbA1c exams at MMC, a coordinated approach involving a diverse group of stakeholders is crucial. The primary stakeholders include the diabetes care team, which is comprised of endocrinologists, diabetes educators, primary care physicians, nursing staff, and hospital administration and health policymakers. This group is essential because they each play a significant role in managing, monitoring, and improving diabetes care practices at MMC. The diabetes care team is directly involved in patient management and is responsible for ensuring the consistent performance of HgbA1c tests. Their daily interactions with patients make them ideally suited to implement changes and monitor improvements (Vitale et al., 2020). Hospital administration can facilitate systemic changes, such as updating protocols and allocating resources for staff training. Health policymakers can ensure alignment with regulatory standards and support for necessary interventions through funding and policy adjustments (Schillinger et al., 2023).

Ethical actions for this stakeholder group at MMC involve several vital considerations. First, a patient-centered approach should be prioritized, emphasizing the importance of regular HgbA1c testing for effective diabetes management. This includes ensuring that patients at MMC are well-informed about the significance of these tests and providing support to help them adhere to recommended testing schedules (Kalyani et al., 2024). Additionally, addressing equitable access to care is crucial. MMC must ensure that all patients, regardless of their socio-economic status, have access to necessary testing and follow-up care. This involves providing educational resources and support tailored to diverse patient populations to prevent disparities in diabetes care. Transparency and accountability are also vital. Implementing regular audits and transparent reporting on HgbA1c testing performance at MMC will help maintain accountability and build trust with patients and the community (Murfet, 2021). Furthermore, integrating sustainable practices into care protocols at MMC is essential. This includes developing efficient testing procedures and resource management strategies to ensure that interventions are cost-effective and sustainable over time. Finally, ongoing training and support for healthcare professionals are critical. By providing up-to-date training on best practices in diabetes management and support to prevent staff burnout (Yao et al., 2021). By addressing these ethical and sustainable actions, MMC can enhance its performance on HgbA1c benchmarks, improve patient outcomes, and foster a culture of excellence and equity in diabetes care.

Conclusion

To address MMC underperformance in HgbA1c, foot, and eye exams, it is crucial to implement targeted interventions that stabilize and enhance these metrics. By improving data collection, streamlining procedures, and investing in staff training, MMC can better meet healthcare benchmarks and to improve patient outcomes. These actions will not only resolve operational and financial challenges but also promote equitable and sustainable practices. Ultimately, addressing these issues will strengthen MMC’s commitment to high-quality, patient-centered care and improve overall care quality and efficiency.

References

Alshammari, M., Windle, R., Bowskill, D., & Adams, G. (2021). The role of nurses in diabetes care: A qualitative study. Open Journal of Nursing, 11(08), 682–695. https://doi.org/10.4236/ojn.2021.118058 

Boye, K. S., Thieu, V. T., Lage, M. J., Miller, H., & Paczkowski, R. (2022). The Association between sustained hba1c control and long-term complications among individuals with type 2 diabetes: A retrospective study. Advances in Therapy, 39(5), 2208–2221. https://doi.org/10.1007/s12325-022-02106-4 

Chen, J., Yin, D., & Dou, K. (2023). Intensified glycemic control by HbA1c for patients with coronary heart disease and Type 2 diabetes: A review of findings and conclusions. Cardiovascular Diabetology, 22(1). https://doi.org/10.1186/s12933-023-01875-8 

Garcia, J. F., Peters, A. L., Raymond, J. K., Fogel, J., & Orrange, S. (2022). Equity in medical care for people living with diabetes. Diabetes Spectrum, 35(3), 266–275. https://doi.org/10.2337/dsi22-0003 

Joo, J. Y., & Liu, M. F. (2020). Effectiveness of culturally tailored interventions for chronic illnesses among ethnic minorities. Western Journal of Nursing Research, 43(1), 73–84. https://doi.org/10.1177/0193945920918334 

Kalyani, R. R., Vigo, M. Z. A., Lent, K. J. A., Close, K. L., Das, S. R., Deroze, P., Edelman, S. V., El, A., Kerr, D., Neumiller, J. J., & Norton, A. (2024). Prioritizing patient experiences in the management of diabetes and its complications: An endocrine society position statement. The Journal of Clinical Endocrinology & Metabolism. https://doi.org/10.1210/clinem/dgad745 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Khor, X. Y., Pappachan, J. M., & Jeeyavudeen, M. S. (2023). Individualized diabetes care: Lessons from the real-world experience. World Journal of Clinical Cases, 11(13), 2890–2902. https://doi.org/10.12998/wjcc.v11.i13.2890 

Kime, N., Pringle, A., Zwolinsky, S., & Vishnubala, D. (2020). How prepared are healthcare professionals for delivering physical activity guidance to those with diabetes? A formative evaluation. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-019-4852-0 

Kollipara, U., Varghese, S., Mutz, J., Putra, J., Bajaj, P., Mirfakhraee, S., Tessnow, A., Fish, J., & Ali, S. (2021). Improving diabetic retinopathy screening among patients with diabetes mellitus using the define, measure, analyze, improve, and control process improvement methodology. The Journal for Healthcare Quality (JHQ), 43(2), 126. https://doi.org/10.1097/JHQ.0000000000000276 

Kvarnström, K., Westerholm, A., Airaksinen, M., & Liira, H. (2021). Factors contributing to medication adherence in patients with a chronic condition: A scoping review of qualitative research. Pharmaceutics, 13(7). https://doi.org/10.3390/pharmaceutics13071100 

Murfet, G. (2021). A consensus approach to building diabetes capabilities in the healthcare workforce. Dro.deakin.edu.au. https://dro.deakin.edu.au/articles/thesis/A_consensus_approach_to_building_diabetes_capabilities_in_the_healthcare_workforce/21118507/1 

NHDQR. (2022). NHQDR Data Tools | AHRQ Data Tools. Datatools.ahrq.gov. https://datatools.ahrq.gov/nhqdr 

Schillinger, D., Bullock, A., Powell, C., Fukagawa, N. K., Greenlee, M. C., Towne, J., Gonzalvo, J. D., Lopata, A. M., Cook, J. W., & Herman, W. H. (2023). The national clinical care commission report to congress: Leveraging federal policies and programs for population-level diabetes prevention and control: recommendations from the national clinical care commission. Diabetes Care, 46(2), e24–e38. https://doi.org/10.2337/dc22-0619 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Sin, H., Dao, T., & Huong, L. (2020). Improving efficiency in the health sector: An Assessment of Vietnam’s Readiness for Integration of Care. https://documents.worldbank.org/curated/en/549541589431736979/pdf/Improving-Efficiency-in-the-Health-Sector-An-Assessment-of-Vietnam-s-Readiness-for-Integration-of-Care.pdf 

Vitale, M., Xu, C., Lou, W., Horodezny, S., Dorado, L., Sidani, S., Shah, B. R., & Gucciardi, E. (2020). Impact of diabetes education teams in primary care on processes of care indicators. Primary Care Diabetes, 14(2), 111–118. https://doi.org/10.1016/j.pcd.2019.06.004 

Yao, M., Zhou, X., Xu, Z., Lehman, R., Haroon, S., Jackson, D., & Cheng, K. K. (2021). The impact of training healthcare professionals’ communication skills on the clinical care of diabetes and hypertension: A systematic review and meta-analysis. BMC Family Practice, 22(1), 1–23. https://doi.org/10.1186/s12875-021-01504-x