Essay NHS FPX 6004 Health Care Law and Policy Assessment 3 Dashboard Benchmark Evaluation KP

NHS FPX 6004 Health Care Law and Policy Assessment 3 Dashboard Benchmark Evaluation KP

NHS FPX 6004 Health Care Law and Policy Assessment 3 Dashboard Benchmark Evaluation KP

NHS FPX 6004 Health Care Law and Policy Assessment 3 Dashboard Benchmark Evaluation KP

Assessment 1: Dashboard Benchmark Evaluation

Dashboards provide healthcare organizations with tools for attaining more effective and efficient healthcare delivery for better patient outcomes. In conjunction with the application of information system principles, Dashboards help generate reports used by the executive team to undertake the performance management role for the healthcare workforce. Ghaziesaeidi et al. (2015) note that these tools allow the managers to detect outliers, analyze the root causes of low performance, and develop an execution plan to make improvements.

Many healthcare providers have adopted the procedures and policies to improve organizational, interprofessional, and personal practices to meet healthcare delivery standards. These policies and procedures are disseminated to the healthcare workers to enhance an understanding and clarity on their responsibilities and roles within the organizations. Therefore, healthcare standards and regulations are necessary to achieve compliance to promote patient safety and outcomes. The Mercy Medical Center, Shakopee, MN, uses many benchmark tools to meet the standards of healthcare delivery as laid by the government. Despite this struggle, the Human Resource Specialist at the medical center analyzes the dashboard data, pointing out the deficiencies that necessitate performance developments.

Stroud (2018) defines benchmarking as knowing the performance level within an establishment, its competitors, within the industry, or in additional segments to produce internal actions. The benchmarks from Mercy Medical Center specify contributing factors such as readmission rates, errors in documentation, medical mistakes, and patient safety. Policies at the federal, state, and local levels were also assessed. The assessment revealed outliers and poor performance, prompting an action plan to enhance performance at the facility.


Apart from the features identified earlier, benchmarking tools are also used to measure the quality of patient services, patient safety, and the overall rating of the healthcare society. Therefore, they effectively support organizations to determine better ways to ensure standards are being met. The presented information includes adverse events, infections, staffing, readmission rates, and problems with the supply chain. In Minnesota, the Local Public Health Act is a policy that stipulates the accountability, practices, and responsibility requirements for the state and local government in the region (Minnesota Department of Health, 2018). The Act entails documentation of statewide creativities and provides guidelines for assessing, planning, and implementing plans to increase patient safety and outcomes. Additionally, the policy approves oversight by the commissioner of wellbeing at the state level.

The healthcare organization, Mercy Medical Center, has formed institutional standards indicating readmission rates for diabetes, the number of falls and injuries, documentation mistakes, and errors in medication management for every the local, state, and national requirements. A review of the dashboard helps determine if this organization is meeting the standards set. However, the system of measurement might fail to capture important data available to the provider or in the knowledge of the public. All the relevant information can not be generated from the numbers. Therefore, a reassessment of the dashboard and the numerous or additional aspects will benefit.

Mercy Medical Center Advantages and Disadvantages

Mercy Medical Center, Shakopee, MN dashboard indicates that it fell back by fall and injury rates, readmission rates to the emergency department, and congestion. Visits to the emergency room were very high, averaging 29893, while urgent care visits were 9586. The data showed visits to the speech therapy, occupational therapy, physical therapy, and language therapy units at 28636. This proportion point to the number of falls and injuries at the facility is disturbing. The facility also provided many radiology procedures and attended much cardiac rehabilitation and cardiopulmonary patients. The number of diabetic patients returning to the hospital increased throughout 2019 and in the last three quarters of 2020. Assuming that the number of new diabetes cases recorded is deficient, this data indicates many medical procedure errors committed by physicians offering care to diabetic patients. Compared to the number of patients visiting the various departments, the number of physicians available indicates deficiencies. The ratio is very high, showing that the facility may be suffering delays in delivering care.

Falls occur among hospitalized patients and pose serious threats. They are the most common incidents that thwart the delivery of care. In the U.S., the rate of falls amongst hospitalized patients ranges between 3.3. to 11.5 falls for every 1000 days of hospitalization (Bouldin et al., 2013). The issues with falls at the Mercy Medical Center are specified by the high rate of patients in quest of occupational therapy.

Mistakes in medication and other medical procedures also seem to be a disturbing concern for Mercy Medical Center. The number of eyes, foot, and arm exams for diabetic patients increased continuously within the last three quarters of 2020. This indicates that a great number of patients returned to the facility to receive care and their health showed deterioration. Poor medical procedures can result in adverse events, which are projected to occur about 1.5 million times a year in the U.S. Such errors are costly preventable causes of harm. The country spends nearly $3.5 billion a year due to adverse events.

The other major challenge confronted by the Mercy Medical Center is the high physician-to-patient ratios. The number of patients who visited the facility to receive care was too high compared to the available physicians and volunteers. This metric shows that the facility is at a higher risk of suffering delayed care and congestion. Khatami (2020) specifies that hospital congestion is a severe challenge that leads to delays, patient frustration, and mental health issues for the staff members. The abundance of patients and provider ratio has the potential to lower the quality of care and destroy the hospital’s reputation. In addition, this can cause a longer wait time in the emergency room and increase admission to inpatient units. This explains why Mercy Medical Center is facing higher admission to the emergency department and urgent care unit than any other unit.

NHS FPX 6004 Health Care Law and Policy Assessment 3 Dashboard Benchmark Evaluation KP

 Under-Performance Analysis 

One of the areas of important alarm for Mercy Medical Center is the high readmission rates to several departments. Most particularly, the number of patients visiting every day to the hospital to receive diabetes evaluation and treatment increased in 2019 and the end of 2020. Kripalani et al. (2014) noted that the medical expenses linked to readmissions were very high, valued the annual cost of around $17.4 billion by Medicare coverage.

The Hospital Readmission Reduction Program (HRRP) was developed to work with hospitals and other facilities to receive payment from Medicaid. In the past hospital were seeing patients for the same treatments and Medicaid did not want to pay for readmission. The Afford Care Act implemented HRRP to oversee the program. This reimbursement covered readmission and other procedures provided. A fraction of the Center for Medicaid and Medicare Services (CMS) reimbursements is capped off for organizations that have higher readmission rates. These financial regulations prompt organizations such as Mercy Medical Center to develop measures that aim to lessen readmission levels.

The Agency for Healthcare Research and Quality (AHRQ) (2020) recognizes some of the actions that can counter the high readmission rates. These include improving the communication and management of care between departments, patients, doctors, nurses, and other health care axillary teams. The improvement of patient education, starting the discharge plan on admission, developing a call-back system after patients are released, and implementing the use of electronic health records (EHR) and aftercare programs. Mercy Medical Center should implement these programs as preventive measures to improve workflow and patient care.

Essay MSN FPX 6021 Quality Improvement Presentation Poster KP

The medical staff at the center must review all orders, medication reconciliation and use a cosigner if needed before delivering medication. The standard for procedures the staff should utilize the time out method to confirm, the right patient, right procedure, and right procedure. Melton (2017) notes that unclear accurate patient education, poor communication, and failure to deliver follow-up appointments are the chief causes of challenges practiced by patients and providers. It is a good practice to provide home health for patients to prevent reoccurring emergency room visits, hospital readmissions and to improve patient health. Further, it improves the hospital satisfaction rate.

The importance of Ethical Action

Practical, ethical action for solving the challenges faced by Mercy Medical Center would consider the organization’s most significant stakeholders. These include the patients and the physicians. The principal goal is to lessen the number of patients readmitted for diabetes care or other chronic conditions. The study included in this report shows that the number of readmissions can be decreased by developing a program that improves the discharge process, case management, and discharges aftercare follow-ups (Kripalani et al., 2014). Additionally, it is vital to ensure the patient is knowledgeable about their diagnosis by providing pamphlets, booklets, and discharge instructions to promote self-care and independence.

A patient survey system would be beneficial to the facility. This system will allow inpatients to take part in surveys and self-report on their health before and after discharge from the hospital. These surveys will enable Mercy Medica Center to identify the healthcare needs to be prioritized at the facility. Also, the facility needs to adopt telehealth services for remote monitoring of patients after they are released to home or into other facilities such as nursing homes.

NHS FPX 6004 Health Care Law and Policy Assessment 3 Dashboard Benchmark Evaluation KP

Another critical need is for the hospital to increase its provider pool by hiring more physicians and nurse practitioners that could narrow the patient-provider ratio. This will help improve effectiveness in seeing the patients in the emergency room, urgent care, and inpatient with a faster response time and the ability to decongest all the units.


The metrics on the demographics of Mercy Medical Center and the records of care delivered to diabetic patients reveal that the facility requires changes to enhance care delivery and patient outcomes. An evaluation of the organization’s performance goals needs helps create measures to uphold and maintain adherence to standards set by the organization in line with the local, state, and federal requirements. The benchmark scores on performance would be better-quality if they increased the providers and other staff. Improve their technology by Implementing the electronic charting system. This Mercy Medical Center will experience reduced admissions to the emergency room and urgent care units when the recommended measures are followed.


Agency for Healthcare Research and Quality (AHRQ). (2020, October). Preventing Unnecessary Hospital Readmissions: The Role of  Patient Safety Organization (PSO) Program (AHRQ). 

Bouldin, E. D., Andresen, E. M., Dunton, N. E., Simon, M., Waters, T. M., Liu, M., … & Shorr, R. I. (2013). Falls amongst mature patients hospitalized in the United States: occurrence and tendencies. Journal of patient safety9(1), 13. 

Ghazisaeidi, M., Safdari, R., Torabi, M., Mirzaee, M., Farzi, J., & Goodini, A. (2015). Advance  performance dashboards in the healthcare sector: key practical issues. Acta Informatica Medica23(5), 317.

NHS FPX 6004 Health Care Law and Policy Assessment 3 Dashboard Benchmark Evaluation KP

Khatami, M. (2020). Reducing Hospital Congestion Through Improved Inpatient Discharge and Post-Acute Placement: A Stochastic Programming Approach (Doctoral dissertation).

Kripalani, S., Theobald, C. N., Anctil, B., & Vasilevskis, E. E. (2014). Reducing hospital readmission rates: current strategies and future directions. 

Minnesota Department of Health (2018). Local Public Health Act. Minnesota Department of Health., J. (2018). Understanding the reason and use of benchmarking. ISIXSIGMA.

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