Review the performance dashboard for a health care organization, as well as relevant local, state, and federal laws and policies. Then, write a report for senior leaders in the organization that communicates your analysis and evaluation of the current state of organizational performance, including a recommended metric to target for improvement.
In the era of health care reform, many of the laws and policies set 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. This assessment offers an opportunity for you to demonstrate and sharpen your ability to analyze, interpret, and evaluate performance dashboard metrics.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
- Competency 1: Analyze the effects of health care policies, laws, and regulations on organizations, interprofessional teams, and personal practice.
- Analyze challenges that meeting prescribed benchmarks can pose for a heath care organization or an interprofessional team.
- Competency 3: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
- Advocate for ethical action in addressing a benchmark underperformance, directed toward an appropriate group of stakeholders.
- Competency 4: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, for health care policies and law for patients, organizations, and populations.
- Evaluate dashboard metrics with regard to benchmarks set by local, state, or federal health care policies or laws.
- Evaluate a benchmark underperformance in a heath care organization or an interprofessional team that has the potential for greatly improving overall quality or performance.
- Competency 6: Apply various methods of communicating with policy makers, stakeholders, colleagues, and patients to ensure that communication in a given situation is professional, clear, efficient, and effective.
- Communicate evaluation and analysis in a professional and effective manner, writing content clearly and logically, with correct use of grammar, punctuation, and spelling.
- Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
- It is crucial to maintain standards and promote quality in modern health care, 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 by relevant federal, state, and local laws and policies. An understanding of 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.How many health care laws can you name that affect your practice in your current or future workplace? How do they impact your daily work? How many regulatory agencies oversee the types of services your health care organization provides? Which regulatory agencies apply to your workplace setting? Are you familiar with the process of complying with those agencies in order to maintain certification? You might be overwhelmed as you consider these broad questions.
- As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend or family member, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
- What local, state, or federal health care policies or laws set benchmarks and standards reflected in performance dashboards common in your professional area of practice?
- What are the potential challenges or opportunities for health care organizations or interprofessional teams in meeting prescribed performance benchmarks and standards? Factors you might consider include the organization’s mission, its size and resources, operational policies and procedures, and the population the organization serves.
The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The NHS-FP6004 – Health Care Policy and Law Library Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you.
Performance Benchmarking Overview
This activity enables you to review a metrics dashboard and hospital fact sheet to evaluate Mercy Medical Center’s performance relative to local, state, and federal benchmarking requirements.
Benchmarking and Performance Measurement Tools
This article discusses best practices in benchmarking to aid organizations in creating a plan.
- Krause, J. (2017, July 28). Four questions to ask about healthcare benchmarking. Retrieved from http://www.managedhealthcareexecutive.com/benchmar…
These resources examine performance measurement tools and benchmarking used for health care delivery.
- Behrouzi, F., Shaharoun, A. M., & Ma’aram, A. (2014). Applications of the balanced scorecard for strategic management and performance measurement in the health sector. Australian Health Review, 38(2), 208–217.
- Johns Hopkins Medicine. (n.d.). Patient safety and quality. Retrieved from http://www.hopkinsmedicine.org/patient_safety_qual…
- National Committee for Quality Assurance. (n.d.). HEDIS and performance measurement. Retrieved from http://www.ncqa.org/hedis-quality-measurement
Performance Benchmarks Challenges and Benefits
This study outlines key barriers to measuring and benchmarking quality of mental health care, describes innovations currently underway worldwide to mitigate barriers and offers recommendations for improving quality of mental health care.
- Kilbourne, A. M., Beck, K., Spaeth-Rublee, B., Ramanuj, P., O’Brien, R. W., Tomoyasu, N., & Pincus, H. A. (2018). Measuring and improving the quality of mental health care: A global perspective. World Psychiatry, 17(1), 30–38.
This resource discusses future options and challenges with respect to the Affordable Care Act provisions and requirements.
- RAND Corporation. (n.d.). The future of U.S. health care: Replace or revise the Affordable Care Act? Retrieved from https://www.rand.org/health/key-topics/health-poli…
This article explores hospital rankings in the United States and how they provide benefit to organizations and consumers in consideration of the Affordable Care Act.
- Huerta, T. R., Hefner, J. L., Ford, E. W., McAlearney, A. S., & Menachemi, N. (2014). Hospital website rankings in the United States: Expanding benchmarks and standards for effective consumer engagement. Journal of Medical Internet Research, 16(2), e64.
This article discusses key practical issues in the development of performance dashboards.
- Ghazisaeidi, M., Safdari, R., Torabi, M., Mirzaee, M., Farzi, J. & Goodini, A. (2015). Development of performance dashboards in healthcare sector: Key practical issues. Acta Informatica Medica, 23(5), 317–321.
Health Care Policies, Laws, Legislation, and Metrics
This resource explains current health care policy in the United States.
- Oliver, T. R. (Ed.). (2014). Guide to U.S. health and health care policy. Washington, DC: CQ Press.
This article discusses the most significant reforms to the U.S. health care system as provisions and mandates in the Affordable Care Act.
- Martin, E. J. (2015). Healthcare policy legislation and administration: Patient Protection and Affordable Care Act of 2010. Journal of Health and Human Services Administration, 37(4), 407–411.
This resource discusses the Medicare Access and CHIP Reauthorization Act (MACRA) current payment pathways for physicians relative to quality measures and benchmarks.
- American Medical Association. (n.d.). Quality payment program specifics. Retrieved from https://www.ama-assn.org/practice-management/quali…
Additional Resources for Further Exploration
Capella provides a thorough selection of online resources to help you understand APA style and use it effectively. Please visit Capella’s APA Style and Format for more information.
Dashboard and Health Care Benchmark Evaluation Simulation
Use the simulation dashboard for your evaluation, review the dashboard, as well as relevant local, state, and federal laws and policies. Consider the metrics within the dashboard that are falling short of prescribed benchmarks.
Structure your report in such a way that it would be easy for a colleague or supervisor to locate the information they need. Be sure to cite relevant local, state, or federal health care laws or policies when evaluating metric performance against prescribed benchmarks. Cite an additional 2–4 credible sources to support your analysis and evaluation of the challenges in meeting the benchmarks, the potential for performance improvement, and your advocacy for ethical action.In your report, be sure to:
- Evaluate dashboard metrics against the benchmarks set by local, state, or federal health care laws or policies.
- Which metrics are below the mandated benchmarks in the organization? Evaluate weaknesses within the entire set of benchmarks.
- What are the local, state, or federal health care laws or policies that set these benchmarks?
- Analyze challenges that meeting prescribed benchmarks can pose for the organization or for an interprofessional team.
- What are the specific challenges or opportunities that the organization or interprofessional team might have in meeting the benchmarks? For example, consider:
- The strategic direction of the organization.
- The organization’s mission.
- Available resources:
- Operational and capital funding.
- Physical space.
- Support services (any ancillary department that supports a specific care unit in the organization, such as a pharmacy, cleaning services, and dietary services).
- Cultural diversity in the organization.
- Cultural diversity in the community.
- Organizational processes and procedures.
- How might these challenges be contributing to benchmark underperformance?
- What are the specific challenges or opportunities that the organization or interprofessional team might have in meeting the benchmarks? For example, consider:
- Evaluate a benchmark underperformance in the organization or interprofessional team that has the potential for greatly improving overall quality or performance.
- Which metric is underperforming its benchmark by the greatest degree?
- Which benchmark underperformance is the most widespread throughout the organization or interprofessional team?
- Which benchmark affects the greatest number of patients?
- Which benchmark affects the greatest number of staff?
- How does this underperformance affect the community the organization serves?
- Where is the greatest opportunity for improvement in the overall quality or performance of the organization or interpersonal team—and ultimately in patient outcomes?
- Advocate for ethical action in addressing the benchmark underperformance that has the potential for greatly improving overall quality or performance.
- At which group of stakeholders should your advocacy be directed? Which group could be expected to take the appropriate action to improve the benchmark metric?
- What are some ethical actions that the stakeholder group could take that support improved benchmark performance?
- Why should the stakeholder group take action?
- Communicate your findings and recommendations in a professional and effective manner.
- Ensure that your report is well organized and easy to read.
- Write clearly and logically, using correct grammar, punctuation, and mechanics.
- Integrate relevant sources to support your arguments, correctly formatting source citations and references using current APA style.
- Did you cite relevant local, state, or federal health care laws or policies when discussing the mandated benchmarks?
- Did you cite an additional 2–4 credible sources to support your analysis, evaluation, and advocacy?
Note: Your faculty may also use the Writing Feedback Tool to provide feedback on your writing. In the tool, click the linked resources for helpful writing information.
Expert Solution Preview
In today’s healthcare landscape, organizations must adhere to a variety of laws, policies, and regulations at the local, state, and federal levels. Compliance with these guidelines is integral to achieving performance benchmarks and delivering quality care to patients. As a medical professor in charge of creating college assignments for medical college students, it is essential to understand the importance of evaluating and analyzing organizational performance metrics.
In this report, we will evaluate the current state of organizational performance at Mercy Medical Center and provide senior leaders with an analysis and evaluation of the metrics displayed on their performance dashboard. Additionally, we will recommend a metric to target for improvement, which will enhance overall quality and performance within the organization.
Analysis and Evaluation of Organizational Performance:
Mercy Medical Center’s performance dashboard indicates that the organization is falling short of prescribed benchmarks in several areas. The first area of concern relates to hospital-acquired infections (HAIs), specifically central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). Both of these metrics fall below the benchmark set by the Centers for Disease Control and Prevention (CDC).
Additionally, Mercy Medical Center is not meeting the benchmark for 30-day readmission rates for patients with heart failure, which is set by the Hospital Readmissions Reduction Program. Finally, the organization’s rate of early elective deliveries (EEDs) is also below the benchmark set by The Joint Commission.
Addressing Benchmark Underperformance:
To address the benchmark underperformance identified in Mercy Medical Center’s performance dashboard, we recommend focusing on reducing the rate of HAIs. Since CLABSI and CAUTI rates are below the CDC benchmark, Mercy Medical Center should implement evidence-based practices to reduce the incidence of these infections. These practices should include training staff on proper catheter insertion and maintenance techniques, monitoring and observing adherence to best practices, and implementing a standardized protocol for removing urinary catheters.
Ethical Action in Addressing Benchmark Underperformance:
It is crucial for Mercy Medical Center to take ethical action in addressing the benchmark underperformance mentioned above. By reducing the incidence of HAIs, the organization will improve patient safety and overall quality of care. We recommend directing this action towards hospital leadership, clinical staff, and quality management teams.
Evaluation of Dashboard Metrics and Benchmarks:
As mentioned earlier, Mercy Medical Center is not meeting several benchmarks related to quality care delivery outcomes. By analyzing the dashboard metrics, we can see that CLABSI and CAUTI rates are below CDC benchmarks, indicating a need for change. Similarly, the 30-day readmission rate for heart failure and rate of early elective deliveries (EEDs) is below the benchmarks set by the Hospital Readmissions Reduction Program and The Joint Commission, respectively.
It is evident that meeting prescribed benchmarks can pose challenges for healthcare organizations and interprofessional teams. Factors such as the organization’s mission, resources, operations, and population served can impact the ability to meet these benchmarks. By focusing on reducing HAIs, Mercy Medical Center can work towards achieving best practices and improving quality of care.
In conclusion, it is crucial for healthcare organizations to understand the impact of laws, policies, and regulations on their performance and quality of care delivery. By analyzing and evaluating performance dashboard metrics, healthcare organizations like Mercy Medical Center can work to address benchmark underperformance and improve overall quality and patient safety. Our recommended metric to target for improvement is reducing the rate of HAIs, specifically CLABSI and CAUTI, by implementing evidence-based practices and standardizing protocols. By taking ethical action and collaborating across interprofessional teams, Mercy Medical Center can work towards achieving benchmarks and delivering quality care to patients.