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Dashboard Metrics Evaluation

NHS-FPX6004 Healthcare Law and Policy

22-5- 2024

Mercy Medical Center’s Dashboard Metrics Evaluation

Healthcare organizations should operate competitively in areas such as quality care, services, and benchmarking, with clearly defined goals and objectives to achieve satisfactory results for patients and society (Novitasari, 2022). To achieve these objectives, it is crucial for healthcare organizations to revisit their mission and vision statements with stakeholders and the board of directors, especially if these statements are not currently the focus. This ensures that the main emphasis remains on helping people achieve better wellness. Benchmarking is vital within healthcare facilities as it allows for comparing the performance of these facilities against both local and national benchmarks.

Diabetes Care Benchmarking

Upon comparing Mercy Medical Centre’s benchmarks in diabetes care to state and national standards, it became evident that while Mercy is close to the benchmarks for eye exams and foot testing, it meets the target for HgbA1c compared to state benchmarks and is nearly meeting national standards. However, Mercy Medical Clinic underperforms in foot checks for the same patient group, with only 60% of patients receiving exams, falling 22.9% below the state average of 82.9% and 24% below the national average of 84% (Mercy Medical Center). In assessing the clinic’s HgbA1c benchmarks, Mercy Medical Centre is only 1.4% below the Minnesota state target and within 10.5% of the national target. Although Mercy meets 90% of the state’s benchmark, it falls 3% short of achieving 90% at the national level (Mercy Medical Centre).

When healthcare guidelines or standards are not achieved, there are significant implications for organizations and interprofessional teams. In the context of Mercy Medical Centre (MMC), there are many consequences of failing to meet diabetic care benchmarks. First, failing to attain these benchmarks can have adverse impacts on clients and their satisfaction levels. For example, with only 59% of patients with diabetes aged 40 or older receiving an eye examination within the year, MMC has performed worse than the state and national averages (Mercy Medical Center). Consequently, patients are more likely to develop diabetic retinopathy and other eye complications, which can negatively impact their overall health. Similarly, a low foot check rate increases the likelihood of diabetic foot complications, such as ulcers and infections, leading to high morbidity among patients.

Secondly, the organization’s inability to meet benchmarking indicators highlights the poor quality and competitiveness of healthcare organizations like MMC. When quality signals are crucial for patient choice and referral patterns, poor performance on key indicators demonstrates the organization’s inefficiency in providing high-quality care (Kharazishvili et al., 2020).

Analysis of the Benchmarks Provided by Local, State, or Federal Healthcare Laws or Policies

According to the Healthcare Effectiveness Data and Information Set (HEDIS), the current national average rate of performing annual eye examinations among diabetics is 75%, and for foot exams, it is 84% (Wadhera et al., 2020). These benchmarks can be used to establish the competency level of a healthcare organization like Mercy Medical Center. CMS also specifies different quality measures for diabetes management under MIPS. These include maintaining an HgbA1c level of 52–70, comprehensive annual eye exams and foot care, and patient education (Diabetes Self-Management Education) (Wadhera et al., 2020). Achieving these parameters is strategic for healthcare organizations regarding payment reimbursement strategies and penalties established by CMS.

Analysis of Mercy Medical Centre’s Performance Against Established Benchmarks

Mercy Medical Centre has significant room for improvement to meet the diabetic care standards set by NCQA and CMS. The clinic, on average, only conducts eye exams for 59% of its members annually, falling short of the HEDIS standard of a minimum of 75%. Additionally, 60% of foot exams are conducted, which is below the 84% target, and the rate of foot ulceration risk assessment is only 2% (Mercy Medical Center). These deficiencies may indicate problems related to both contacting patients and discussing with them the need for such screenings, as well as timely scheduling. In terms of HgbA1c control, Mercy Medical Centre performs better, with rates only slightly below the Minnesota state target of 10 (Mercy Medical Center). This performance is 5% below the national goals and suggests areas for improvement, particularly in the vigilant follow-up of patients’ blood sugar levels (Narayan et al., 2024).

Staffing and training needs

Proper staffing with well-trained personnel who can dedicate sufficient time to educate patients about the importance of tests is critical (Kimbell et al., 2020). Understaffing and inadequate training in patient education and test scheduling are major reasons for underperformance in eye and foot testing. Additionally, a lack of diversity among staff may reduce patient trust and compliance.

Building trust and respect with patients is vital for their adherence to prescribed treatments (Peimani et al., 2020). Mercy Medical Centre must prioritize improving patient care to avoid severe consequences, including patient distrust, inadequate staffing, and insufficiently trained personnel. Diabetes, characterized by high blood glucose due to insulin deficiencies, can lead to severe complications such as heart disease, stroke, blindness, and kidney disease if not controlled. Diabetes affects approximately 37.3 million people in the United States, with an additional 122.4 million individuals being pre-diabetic (Levy, 2021).

Recommendation

Since Mercy Medical Centre is underperforming on diabetes care benchmarks, the hospital should promote ethical and sustainable strategies involving its main stakeholders, including the board of directors and the community. Specifically, it is recommended to invest in increasing the number of staff, their training, and purchasing more testing equipment. This approach aligns with ethical values such as excellence in patient care, equality in health, and sustainable development by enhancing human capital and patients’ overall well-being.

Recognizing the critical need to maintain competitive quality of patient care and achieve exceptional patient satisfaction, this paper recommends that a collective group of stakeholders, including the board of directors, commit capital funds to enhance staffing through comprehensive training and increased availability of proper testing equipment. Investing in our workforce to ensure all employees receive full training is crucial to maintaining high standards of care. Additionally, purchasing more testing equipment will enable more comprehensive and routine tests, thereby improving diagnostic accuracy and patient outcomes. 

Engaging patients and healthcare practitioners to foster their support for identifying and addressing underperformance areas will help reduce mistakes and improve outcomes. Focusing on resource allocation and management will ensure our facility remains the premier provider of healthcare quality and patient satisfaction. Allocating funds for staffing, training, and equipment will yield a good return on investment and keep us competitive. This investment will enhance human resources with adequate education, improve service competencies, and increase patient confidence, ultimately improving the community’s health status.

In the long run, this will create a sustainable business model and promote growth. Implementing accurate benchmarking and achieving higher patient satisfaction will differentiate our organization from competitors, reinforcing our brand promise of quality and reliable healthcare solutions. Human resources and the extensive use of better-quality equipment are key areas that contribute to long-term planning and a strong market position. As discussed, investing in these areas will greatly benefit our patients and improve overall health outcomes across our organization.

However, the ethics of a healthcare organization should focus on the patients. A principal element of this is the provision of benchmarks, which help us understand how our facility compares to state and national averages. Without these benchmarks, Mercy Medical Centre may not be able to conduct its operations effectively due to strict operational guidelines set by laws and regulations. We must perform certain practices with patients and compare the results to avoid providing unsatisfactory or dangerous health services.

In summation, the clinic must recruit enough competent human resources who can spend time with patients to explain the relevance of specific tests and how they assist in monitoring diabetes. If the clinic has few employees or the current employees lack the ability to educate patients and schedule tests, poor results will be observed in indicators such as eye and foot tests. Training and appropriately staffing our team, while increasing our testing capacity, will significantly improve our benchmarks. This will not only enhance quality but also ensure that Mercy Medical Centre can compete and remain compliant with state and national regulatory requirements.

Investing in these areas will not only meet standards but also bring substantial improvements in patient outcomes, which will be appreciated and supported by the community we serve. It is a strategic investment in the facility’s human and technical resources, aimed at delivering outstanding patient care and fostering healthier communities.

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References

Kimbell, B., Rankin, D., Ashcroft, N. L., Varghese, L., Allen, J. M., Boughton, C. K., … & CLOuD Consortium. (2020). What training, support, and resourcing do health professionals need to support people using a closed-loop system? A qualitative interview study with health professionals involved in the closed loop from onset in type 1 diabetes (CLOuD) trial.
Diabetes technology & therapeutics,
22(6), 468-475.retrieved from:
https://www.liebertpub.com/doi/pdf/10.1089/dia.2019.0466

Kharazishvili, Y., Kwilinski, A., Grishnova, O., & Dzwigol, H. (2020). Social safety of society for developing countries to meet sustainable development standards: Indicators, level, strategic benchmarks (with calculations based on the case study of Ukraine). 
Sustainability, 
12(21), 8953.
https://www.mdpi.com/2071-1050/12/21/8953

LEVY, L. A. (2021). The exploding incidence and prevalence of diabetes.
The Diabetic Foot. Retrieved from:
https://podiatrym.com/pdf/2021/4/Levy421Web.pdf

Mercy Medical Center (Shakopee, MN)

Narayan, A., Kocher, B., & Shah, N. R. (2024). Improving The Quality Of Quality Metrics. 
Health Affairs Forefront.
https://www.healthaffairs.org/content/forefront/improving-quality-quality-metrics

Novitasari, D. (2022). Hospital Quality Service and Patient Satisfaction: How The Role of

Service Excellent and Service Quality?.
Journal of Information Systems and Management

(JISMA),
1(1), 29-36. Retrieved from:
https://jisma.org/index.php/jisma/article/view/255

Peimani, M., Nasli-Esfahani, E., & Sadeghi, R. (2020). Patients’ perceptions of patient–provider communication and diabetes care: A systematic review of quantitative and qualitative studies.
Chronic illness,
16(1), 3-22.retrieved from:
https://journals.sagepub.com/doi/pdf/10.1177/1742395318782378

Pourkazemi, A., Ghanbari, A., Khojamli, M., Balo, H., Hemmati, H., Jafaryparvar, Z., & Motamed, B. (2020). Diabetic foot care: knowledge and practice.
BMC endocrine disorders,
20, 1-8. Retrieved from:
https://link.springer.com/article/10.1186/s12902-020-0512-y

Wadhera, R. K., Figueroa, J. F., Maddox, K. E. J., Rosenbaum, L. S., Kazi, D. S., & Yeh, R. W. (2020). Quality measure development and associated spending by the Centers for Medicare & Medicaid Services. 
JAMA, 
323(16), 1614-1616.
https://jamanetwork.com/journals/jama/article-abstract/2764986