Healthcare Law and Policy Dashboard Metrics Evaluation

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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 (, n.d.). The MMC chief

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

the quality assurance department (, 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


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 (, 2019).

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

(, 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.


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

Healthcare Research & Quality.

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

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.

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).

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

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

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

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

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

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).

This study source was downloaded by 100000855641916 from on 01-25-2023 15:00:49 GMT -06:00 by TCPDF (

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