Preparation
For this assessment, you may choose one of the following three options for a performance dashboard to use as the basis for your benchmark evaluation.
Option 1: Dashboard and Health Care Benchmark Evaluation Simulation
If you decide to use one of the simulation dashboards for your evaluation, review both dashboards, as well as the relevant local, state, and federal laws and policies linked in each dashboard. Choose one of the dashboards and consider the metrics within it that are falling short of the prescribed benchmarks.
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.
Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.
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.
Competency Map
Report Requirements
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.
Note: The tasks outlined below correspond to grading criteria in the scoring guide.
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:
. Staffing.
. 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?
· 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?
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://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/four-questions-ask-about-healthcare-benchmarking?page=0,0
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_quality_dashboard/understanding_performance_metrics/core_measures.html
· 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., Spaethâ€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-policy/in-depth.html
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/quality-payment-program-qpp-specifics
·
Dashboard and Health Care Benchmark Evaluation
Introduction
Dashboards and other reports can provide crucial information about how well an organization is meeting benchmarks set by local, state, and federal laws and policies. Healthcare organizations need to be able to use this information to determine the most effective strategies for quality and performance improvement. This activity asks you to review various dashboards and reports used by Mercy Medical Center, a Vila Health affiliated hospital, and determine where the organization is falling short.
Scatterdesk
Voice Mail
Evelyn Unger
Senior Human Resources Generalist
Hey there. This is Evelyn Unger; sorry I missed you. I just wanted give you a little more context for the report you’ve been asked to pull together on our dashboard metrics. The main thing is that we’re trying to get a better understanding of how to evaluate the information these dashboards are providing. The goal is to be able to use the data as actionable information.
So – if you could review the materials I’ve provided to you and use one of the two dashboards as the source of the data, that would be great. You’ll need to do some external research probably in order to determine external benchmarks and standards. Oh … and remember that while there may be a couple of underperforming areas, your recommendations should be based on the actions that will deliver the best improvement to overall quality or performance.
Let me know if you have any questions.
Public Health Dashboard – Diabetes
New Patients Last Quarter by Race
· African American – 17 (3%)
· American Indian – 73 (13%)
· Asian – 34 (6%)
· White – 355 (63%)
· Other – 11 (2%)
· Blank/Declined – 73 (13%)
New Patients Last Quarter by Gender
· Male – 214 (38%)
· Female – 347 (62%)
· Blank/Declined – 2
New Patients Last Quarter by Age
· 20 or younger – 118 (21%)
· 21-44 – 51 (9%)
· 45-64 – 214 (38%)
· 65+ – 180 (32%)
· Blank/Declined – 0
| Q1 2015 | Q2 2015 | Q3 2015 | Q4 2015 | Q1 2016 | Q2 2016 | Q3 2016 | Q4 2016 | |
| Eye Exam | 4 | 16 | 7 | 33 | 41 | 28 | 16 | 27 |
| Foot Exam | 2 | 5 | 27 | 48 | 73 | 62 | 7 | 3 |
| HgbA1c | 1 | 11 | 23 | 87 | 123 | 32 | 13 | 6 |
2016 Fact Sheet
Mercy Medical Center (Shakopee, MN)
Mercy Medical Center is one of the region’s top choices for high quality health care. Don’t just take our word for it though. Here are some of the accolades we’ve received:
· Highest Safe Surgery Rating by a consumer advocacy magazine.
· Healthgrades Outstanding Patient Experience Award.
· Shakopee Ledger Top 20 Workplaces 2014 & 2015.
· Women’s Choice Award for the Best Hospital for Patient Experience in Emergency Care.
Shakopee Demographics
| Female | Male | Total Population |
| 18,235 | 17,957 | 36,192 |
| < 20 | 21-44 | 45-64 | > 65 |
| 12,126 | 14,732 | 6,099 | 2,371 |
| White | Asian | Hispanic – Latino | Other | African American | Two or more races | American Indian |
| 28,537 (76%) | 3,822 (10%) | 2,890 (7%) | 1,661 (4%) | 1,601 (4%) | 1,016 (4%) | 433 (1%) |
Shakopee Ledger
Top 20 Workplaces 2014 & 2015
| 2005 | 2015 | |
| Hospital Rooms (All Private) | 62 (70 licensed) | 85 (93 licensed) |
| Medical / Surgical Rooms | 33 | 56 |
| Special Care Unit | 8 | 8 |
| Family Birth Rooms | 17 | 17 |
| Children’s Care Pediatric Rooms | 4 | 4 |
| Operating Rooms | 5 and 1 C – Section | 8 and 1 C – Section |
| Emergency Room Treatment Bays | 16 | 21 |
| Endoscopy Rooms | 2 | 2 |
| 2015 | |
| Physicians | 433 |
| Volunteers (15 — 94 yeard old) | 200 |
| Inpatient Admissions | 5,735 |
| Surgical Procedures | 4,627 |
| Births | 1,328 |
| Emergency Room Visits | 29,893 |
| Urgent Care Visits | 9,586 |
| Outpatient Encounters | 119,535 |
| Physical, Occupational, Speech/Language Therapy Visits | 28,636 |
| Pediatric Therapy Visits | 11,987 |
| Sleep Center Visits | 783 |
| Radiology Procedures | 59,335 |
| Cardiac Rehab Visits | 7,158 |
| Cardiopulmonary Visits | 19,676 |
| Cancer Center Visits | 7,781 |
Hospital CEO Dashboard
Local Readmission Rates
| COPD | Pneumonia | Heart Failure |
| 20.1 (31%) | 18.7 (29%) | 26.4 (40%) |
National Readmission Rates
| COPD | Pneumonia | Heart Failure |
| 20.2 (34%) | 16.9 (29%) | 22.0 (37%) |
Medical & Surgery
| Falls | Medication Errors | Pressure Sores | Patient Injuries | Documentation Errors |
| 2015 = 14 / 2016 = 10 | 2015 = 4 / 2016 = 8 | 2015 = 4 / 2016 = 3 | 2015 = 3 / 2016 = 4 | 2015 = 3 / 2016 = 4 |
Labor & Delivery
| Falls | Medication Errors | Pressure Sores | Patient Injuries | Documentation Errors |
| 2015 = 3 / 2016 = 0 | 2015 = 5 / 2016 = 0 | 2015 = 0 / 2016 = 0 | 2015 = 1 / 2016 = 0 | 2015 = 9 / 2016 = 1 |
Orthopedics
| Falls | Medication Errors | Pressure Sores | Patient Injuries | Documentation Errors |
| 2015 = 8 / 2016 = 10 | 2015 = 2 / 2016 = 2 | 2015 = 5 / 2016 = 3 | 2015 = 4 / 2016 = 4 | 2015 = 4 / 2016 = 3 |
Bariatric Services
| Falls | Medication Errors | Pressure Sores | Patient Injuries | Documentation Errors |
| 2015 = 16 / 2016 = 18 | 2015 = 7 / 2016 = 7 | 2015 = 4 / 2016 = 3 | 2015 = 3 / 2016 = 1 | 2015 = 16 / 2016 = 23 |
| Average Daily Census | Average Daily RN FTEs | Scheduled RN FTEs | |
| ICU | 18 | 11 | 14 |
| PICU | 17 | 12 | 13.5 |
| Med Surg | 23 | 14 | 16 |
| Labor and Delivery | 16 | 10 | 10 |
| Orthopedics | 12 | 6.25 | 6.5 |
| West 1 | 20 | 13 | 15.25 |
| West 2 | 13 | 8.5 | 9.5 |
| North 1 | 18 | 9.75 | 12.75 |
Conclusion
In this activity, you had the opportunity to review various dashboards and other reports in order to evaluate Mercy Medical Center’s performance against local, state, and federal requirements. Use the information you acquired here as well as external research into appropriate standards to complete your course assignment.
Credits
Subject Matter Expert:
Bressie, Marylee
Interactive Design:
Olson, Lori
Media Instructional Designer:
Pearson, Felicity
Instructional Designer:
Hagen, Brian
Project Manager:
Hall, Nakeela
Licensed under a Creative Commons Attribution 3.0 License
Dashboard Benchmark Evaluation Scoring Guide
| CRITERIA | NON-PERFORMANCE | BASIC | PROFICIENT | DISTINGUISHED |
| Evaluate dashboard metrics with regard to benchmarks set by local, state, or federal health care policies or laws. | Does not analyze dashboard metrics with regard to benchmarks set by local, state, or federal health care policies or laws. | Analyzes dashboard metrics, but relationship to benchmarks set by local, state, or federal health care policies or laws is missing or flawed. | Evaluates dashboard metrics with regard to benchmarks set by local, state, or federal health care policies or laws. | Evaluates dashboard metrics with regard to benchmarks set by local, state, or federal health care policies or laws, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the evaluation). |
| Analyze challenges that meeting prescribed benchmarks can pose for a heath care organization or an interprofessional team. | Does not list challenges that meeting prescribed benchmarks can pose for a heath care organization or an interprofessional team. | Lists but does not analyze challenges that meeting prescribed benchmarks can pose for a heath care organization or an interprofessional team, or provides a flawed analysis that misses key challenges. | Analyzes challenges that meeting prescribed benchmarks can pose for a heath care organization or an interprofessional team. | Analyzes challenges that meeting prescribed benchmarks can pose for a heath care organization or an interprofessional team, and identifies assumptions on which the analysis is based. |
| Evaluate a benchmark underperformance in a heath care organization or an interprofessional team that has the potential for greatly improving overall quality or performance. | Does not evaluate a benchmark underperformance in a heath care organization or an interprofessional team that has the potential for greatly improving overall quality or performance. | Provides a partial or flawed evaluation of a benchmark underperformance in a heath care organization or an interprofessional team; misses factors that are key to understanding the potential for improving overall quality or performance. | Evaluates a benchmark underperformance in a heath care organization or an interprofessional team that has the potential for greatly improving overall quality or performance. | Evaluates a benchmark underperformance in a heath care organization or an interprofessional team that has the potential for greatly improving overall quality or performance, and defends reasoning for selecting this benchmark over another with similar potential for improvement. |
| Advocate for ethical action in addressing a benchmark underperformance, directed toward an appropriate group of stakeholders. | Does not advocate for ethical action in addressing a benchmark underperformance, directed toward an appropriate group of stakeholders. | Attempts to advocate for ethical action but attempt is flawed, superficial, or does not address an appropriate group of stakeholders. | Advocates for ethical action in addressing a benchmark underperformance, directed toward an appropriate group of stakeholders. | Advocates for ethical action in addressing a benchmark underperformance, directed at an appropriate group of stakeholders, and recommends criteria for evaluating the effectiveness of recommended action. |
| Communicate evaluation and analysis in a professional and effective manner, writing content clearly and logically, with correct use of grammar, punctuation, and spelling. | Does not communicate evaluation and analysis findings and recommendations in a professional and effective manner; does not write content clearly and logically, and does not use correct grammar, punctuation, and spelling. | Communicates evaluation and analysis findings and recommendations that are not consistently professional, effective, clear, and logical, or that contain errors in use of grammar, punctuation, or spelling that distract from the message. | Communicates evaluation and analysis in a professional and effective manner, writing content clearly and logically, with correct use of grammar, punctuation, and spelling. | Communicates evaluation and analysis findings and recommendations that are professional, effective, and insightful; the content is clear, logical, and persuasive; and grammar, punctuation, and spelling are without errors. |
| Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style. | Does not integrate relevant sources to support arguments; does not correctly format citations and references using current APA style. | Cites sources that lack relevance or integrates them poorly, or formats citations or references incorrectly. | Integrates relevant sources to support arguments, correctly formatting citations and references using current APA style. | Integrates relevant sources to support arguments, correctly formatting citations and references using current APA style. Citations are free from all errors. |
