Write a 4-6-page report for a senior leader that communicates your evaluation of current organizational or interprofessional team performance, with respect to prescribed benchmarks set forth by government laws and policies at the local, state, and federal levels. In addition, advocate for ethical action to address benchmark underperformance and explain the potential for improving the overall quality of care and performance, as reflected on a performance dashboard.

Introduction

In the era of health care reform, many of the laws and policies set forth 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.

Maintaining standards and promoting quality in modern health care are crucial, 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 forth 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.

Note: Your evaluation of dashboard metrics for this assessment is the foundation on which all subsequent assessments are based. Therefore, you must complete this assessment first.

Write a report for a senior leader that communicates your evaluation of current organizational or interprofessional team performance with respect to prescribed benchmarks set forth by government laws and policies at the local, state, and federal levels. In addition, advocate for ethical action to address benchmark underperformance and explain the potential for improving the overall quality of care and performance, as reflected on a performance dashboard.

Review the performance dashboard metrics, as well as relevant local, state, and federal laws and policies. Consider the metrics that are falling short of the prescribed benchmarks. Structure your report so that it will be easy for a colleague or supervisor to locate the information they need, and be sure to cite the relevant health care policies or laws when evaluating metric performance against established benchmarks.

Preparation

Choose one of the following three options for a performance dashboard to use as the basis for your evaluation:

Option 1: Dashboard Metrics Evaluation Simulation

Use the data presented in the Dashboard and Health Care Benchmark Evaluation multimedia activity as the basis for your evaluation.

Note: The writing that you do as part of the simulation could serve as a starting point to build upon for this assessment.

Option 2: Actual Dashboard

Use an actual dashboard from a professional practice setting for your evaluation. If you decide to use actual dashboard metrics, be sure to add a brief description of the organization and setting that includes:

  • The size of the facility that the dashboard is reporting on.
  • The specific type of care delivery.
  • The population diversity and ethnicity demographics.
  • The socioeconomic level of the population served by the organization.

Note: Ensure your data are Health Insurance Portability and Accountability Act (HIPAA) compliant. Do not use any easily identifiable organization or patient information.

Option 3: Hypothetical Dashboard

If you have a sophisticated understanding of dashboards relevant to your own practice, you may also construct a hypothetical dashboard for your evaluation. Your hypothetical dashboard must present at least four different metrics, at least two of which must be underperforming the prescribed benchmark set forth by a federal, state, or local laws or policies. In addition, be sure to add a brief description of the organization and setting that includes:

  • The size of the facility that the dashboard is reporting on.
  • The specific type of care delivery.
  • The population diversity and ethnicity demographics.
  • The socioeconomic level of the population served by the organization.

Note: Ensure your data are HIPAA compliant. Do not use any easily identifiable organization or patient information.

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Dashboard Metrics Evaluation Example
Note: The dashboards and data presented in this example assignment are made up. Do not use
them in developing your own report. They’re provided only as examples of how data could be
formatted and referred to when you create your report.
The first section of this example shows two dashboards containing metrics that the evaluation is
based upon. Be sure to reference the data from the Dashboard and Health Care
Benchmark Evaluation simulation in your evaluation.
The second section is the evaluation of the data presented in the metrics and represents
proficient-level work for all of the criteria in the scoring guide.

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Sepsis Dashboards from Eagle Creek Hospital

(Learners: You do not have to include charts like these in your report.)
Third Quarter Sepsis Intervention Compliance

at Eagle Creek Hospital for Adults Presenting with Sepsis

Intervention

Needed

Completed
Compliance
Percentage

Initial lactate within 3 hours 27 27 100%
Blood cultures drawn prior to antibiotics 27 19 70%
Antibiotics administered within 3 hours 27 24 89%
Fluid resuscitation if in septic shock within 3
hours 17 15 88%

Vasopressors if hypotension persists after
fluid resuscitation or lactate > 4mmoL/L within
6 hours

10

6

60%

Overall 108 91 84%

Third Quarter Sepsis Intervention
Compliance and Inpatient Mortality (Sample)

Patient ID
# of Interventions

Needed
# of Interventions

Completed

Inpatient Mortality
1000 3 2 0

1009 4 4 1
1014 5 5 0
1017 5 5 0
1060 3 1 1
1074 5 4 1
1084 4 2 1
1087 5 5 0
1094 3 3 0
1106 4 4 0

Note: The staffing benchmark for nurse staffing in this unit is 2 patients per nurse.
Monthly average staffing for the unit is 2 nurse workload units. The average number of
patients in the unit per month in the third quarter was 6.75.

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To the Director of Safety Compliance:

I have reviewed the data that you sent my way regarding our compliance with sepsis

measures and intervention compliance, plus the sample of our third quarter inpatient mortality.

The following contains my evaluation of the data, which shows that there are definitely areas

that the organization needs to improve, as well as a proposal for a specific area and target for

improvement.

Evaluation of dashboard metrics

There are numerous underperformances in the metrics regarding compliance for sepsis

measures at Eagle Creek Hospital. From the dashboard regarding compliance of performing

the prescribed measures and procedures, the two that stand out are the 70%