Dashboard Metrics Evaluation Essay

Dashboard Metrics Evaluation Essay

The goal of healthcare reform is to help the healthcare system to provide highly effective care. Federal and state laws and policies govern these modifications. It is essential to know the bar established by such recommendations and how they can be used to improve care and efficiency. Leveraging benchmarks as a management strategy to implement optimal procedures at the most affordable price is being adopted in the healthcare sector (Kayingo, 2022). Performance metrics should be benchmarked to reflect the quality of care provided accurately. Quality indicators can be broken down into two categories: process measures and outcome measures. Process measures evaluate care delivery, while treatment effectiveness is determined by outcome measures (Ma et al., 2019). Healthcare process measures check whether or not patients were given the proper tests and therapeutic interventions. The outcome measures of medical care are evaluated by looking at things like whether or not the patient’s health is enhanced as a result of treatment. Given the importance placed on them by both patients and medical professionals, outcome measures have become the gold standard by which healthcare facilities are assessed (Ma et al., 2019). A dashboard and healthcare benchmark evaluation for Mercy Medical Health, a Villa Health affiliate, has been analyzed for its potential to improve care and quality outcomes.

Dashboard Metric Evaluation and Comparison with State and Federal Healthcare Policy.

Data from Medicare and Medicaid Services (CMS) and the National Healthcare Quality and Disparities Report (NHQDR) were compared with the results from the healthcare organization to ascertain if these standards were met. Several of the examined performance indicators were found to violate state policy regulations. To begin with, there has been a noteworthy change in the published frequencies of foot examinations and HgbA1c tests. Between the first and third quarters of 2019, annual foot exams fell from 60 to 42. In the first and fourth quarters of 2019, the number of HgbA1c tests performed dropped drastically from 60 to 42, and between the first and fourth quarters of 2020, the rate dropped from 72 to 64. Since the number of tests has not steadily increased, the most key insight from the evaluation is that the center is underperforming compared to the benchmarks.


Policies help to provide recommendations and guidance on using benchmarks in different healthcare settings. Some of the policies that help to guide benchmarks include the Affordable Care Act (ACA), National Quality Forum (NQF), and Agency for Healthcare Research and Quality (AHRQ). The Office of Health Strategy (OHS) in the state of Connecticut is in charge of overseeing the benchmarking of medical facilities in the state. The Connecticut Healthcare Innovation Plan, a road plan for enhancing the healthcare system in the state, is one of the widely supported initiatives that has been developed. The strategy contains tactics for boosting the utilization of information and benchmarks to enhance the standard of healthcare while simultaneously reducing expenses. Incomplete data from past years can substantially impact benchmark assessment, leading to biased benchmarks, constrained insights, diminished confidence in the conclusions of benchmark review, and incomplete comparability. To generate credible benchmarks, it is essential to make sure that the historical data is comprehensive and accurate.

Analyze the consequence(s) of not meeting prescribed benchmarks and the impact this has on healthcare organizations or teams.

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Failure to achieve healthcare benchmarks may have far-reaching effects on an organization’s ability to fulfill its stated goals. A healthcare provider’s credibility can take a hit if it falls short of regulatory requirements. There is a risk that patients and other interested parties will see the organization as offering subpar service or failing to deliver on its mission. This might make it challenging for the business to bring in new customers, retain current ones, and keep skilled staff around. Healthcare providers who fall short of targets may see their funding cut. This may happen if the organization’s financing depends on meeting specific benchmarks or if its financial backers, such as insurance companies or government agencies, are unhappy with its overall performance (Willmington et al., 2022).

Consistently underperforming healthcare organizations may have trouble attracting and maintaining quality employees (Willmington et al., 2022). Potential workers might think more carefully before committing to an organization with a bad reputation. Existing employees might decide to quit if they feel they cannot give enough care. The morale of healthcare workers can suffer if they are not meeting adequate standards. Employees can feel demoralized when they cannot provide their clients with the necessary care. As a result, productivity and morale can suffer, and turnover rates can rise. Errors and adverse consequences in healthcare are more likely to occur when standards are unmet. Patients could be put in danger if, for instance, the facility consistently falls short of requirements for medication administration or infection prevention and control.

What are the challenges that may potentially contribute to benchmark underperformance?

Inadequate funds, personnel, equipment, or facilities may make it difficult for healthcare institutions to achieve the benchmarks. Organizations may struggle to deliver high-quality treatment and meet the demands of their patients if they do not have sufficient resources (Willmington et al., 2022). Complex medical illnesses and comorbidities in patient groups might make it difficult for healthcare institutions to satisfy benchmarks. Furthermore, healthcare institutions may struggle to keep up with the ever-evolving state of scientific information and technological advances. Complex and ever-evolving regulatory regulations can make it difficult for healthcare organizations to achieve their objectives (Willmington et al., 2022). Violating regulatory standards can result in monetary penalties or legal liabilities.  Healthcare providers may strain to engage patients effectively, although doing so is vital for reaching healthcare benchmarks. It is possible that patients may not want to be involved in care planning or may not know what to do to take responsibility for their health.

The conclusion that numerous obstacles may lead to benchmark underachievement is founded on the premise that healthcare organizations strive to fulfill particular quality and performance criteria. In addition, standards for healthcare are regarded to be valid and accurate measurements of quality and performance. The findings also assume that healthcare providers face various obstacles that may lessen their performance relative to regulatory requirements. Researchers and data collectors in the healthcare industry, along with the expertise and insights of healthcare professionals, enlighten these difficulties.

Benchmark Underperformance

The results of the HgbA1c tests in 2019 were less than ideal. In recent years, the number of people taking the exam has dropped dramatically. Diabetic patients ought to have their HgbA1c assessed frequently. In the fourth quarter of 2019, for instance, 42 patients had this examination. Falling short of patients’ expectations regarding care quality is unacceptable. Mercy Medical Center is one of the best hospitals in the area, making it ideal for doing this glycohemoglobin test. To safeguard the well-being of diabetic patients, the center’s administration should develop policies, and all healthcare providers should follow those regulations. According to Mercy Medical Care, the number of intensive care units has been unchanged from eight during the past decade. As a result, patients will have low expectations regarding how easily they may access treatments at Mercy Medical Center in the future.

There appears to be a similar fall in the number of documented foot exams. A training program to inform the general public about the importance of these tests to service quality and performance is fully justified. Regular screening can help keep diabetes under control or possibly avoid it. Not giving people at risk for complications a diagnosis so they can get prompt treatment is a huge missed opportunity. Individuals are more likely to have positive health outcomes when diabetes is recognized and treated promptly, and hospitals might receive positive feedback for providing excellent treatment. This quality metric may affect several people living near Mercy Medical Center. They will not get the necessary care, and the desirable health objectives may not be achieved. It is suggested that the multidisciplinary group develop a public awareness campaign through education to combat the underachievement problem. This initiative should be accessible to all community members, despite its focus on the needs of those with diabetes.

Ethical and Sustainable Actions

The increasing number of diabetic patients who get foot tests necessitates a multidisciplinary strategy involving multiple stakeholders. Regarding diabetes management, primary care physicians (PCPs) are generally patients’ first and most crucial point of contact. Diabetic individuals can benefit from their assistance in scheduling routine foot inspections and learning how to care for their feet properly. Regular foot assessments may be a part of the comprehensive care plans that endocrinologists and primary care physicians create for diabetes patients (Fermawi et al., 2023). Nurses and nurse practitioners frequently participate in diabetes care, such as blood sugar measurement and patient education. They can aid in making sure diabetes patients have routine foot assessments and offer advice on the importance of coming for these examinations.

Regular foot examinations are critical for diabetes patients to prevent foot issues, which can result in serious health complications and affect their quality of life. Diabetes can cause nerve damage and inadequate blood flow to the feet, increasing the likelihood of foot ulcers, infections, and amputations. Frequent foot examinations can aid in detecting these issues early and preventing them from worsening (Fermawi et al., 2023). Stakeholders can enhance health outcomes and minimize health expenses by raising the number of diabetic patients getting frequent foot inspections. For instance, early identification and management of foot ulcers can prevent hospitalizations and reduce the requirement for costly procedures like amputations (Fermawi et al., 2023). Frequent foot examinations can also aid diabetic people in controlling their glucose levels and preventing problems such as heart disease and renal damage.

The stakeholders can ensure that all patients, regardless of socioeconomic standing, race, or ethnicity, are provided with the required care and services (Franco-Trigo et al., 2020). This has the potential to help eliminate gaps in patient outcomes and guarantees that all individuals can attain their best possible state of health. The stakeholder group can prioritize the patient’s wants and needs when giving them services. Including clients in the decision-making process, ensuring effective communication and education, and honoring patients’ cultural ideas and values should be done by the stakeholders (Franco-Trigo et al., 2020). The organization should guarantee that patient data remains confidential and safe by following the rules and regulations that are currently in effect. This can contribute to developing trust between patients and the healthcare practitioners who treat them and encourage a favorable patient experience.


When assessing their effectiveness, healthcare providers can learn a lot from comparing them against industry standards. Healthcare facilities may better serve their patients, save expenses, and boost the quality of care by analyzing their performance compared to benchmarks and best practices. Nonetheless, there are obstacles to benchmark evaluation; therefore hospitals and clinics should think critically about the reliability and validity of the standards they utilize. For healthcare facilities to see accurate results from benchmarking, they must involve key stakeholders and promote a continuous improvement environment. Healthcare institutions can better guarantee that they are giving their clients the best possible healthcare through benchmark information to motivate efforts to enhance quality and increase patient care.



Fermawi, A., Tolson, P., Knapp, M., Marrero, D., Zhou, W., Armstrong, G., & Tan, W. (2023). Disparities in preventative diabetic foot examination. Seminars in Vascular Surgery. https://doi.org/10.1053/j.semvascsurg.2023.01.001

Franco-Trigo, L., Fernández-Llimós, F., Martínez-Martínez, F., Benrimoj, I., & Sabater-Hernández, D. (2020). Stakeholder analysis in health innovation planning processes: A systematic scoping review. Health Policy, 124(10). https://doi.org/10.1016/j.healthpol.2020.06.012

Ma, J., Wong, M., Micieli, A., Calafati, J., Low, S., El-Defrawy, S., & Hatch, W. (2019). Vision to improve: quality improvement in ophthalmology. Canadian Journal of Ophthalmology. https://doi.org/10.1016/j.jcjo.2019.07.020

Willmington, C., Belardi, P., Murante, M., & Vainieri, M. (2022). The contribution of benchmarking to quality improvement in healthcare. A systematic literature review. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07467-8

Kayingo, G., Bradley-Guidry, C., Burwell, N., Suzuki, S., Dorough, R., & Bester, V. (2022). Assessing and benchmarking equity, diversity, and inclusion in healthcare professions. JAAPA, 35(11), 51–54. https://doi.org/10.1097/01.jaa.0000885184.50730.94


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

Option 1: Dashboard Metrics Evaluation Simulation

Use the data presented in your Assessment 1 Dashboard and Health Care Benchmark Evaluation activity as the basis for your evaluation.

Note: The writing 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.

To complete this assessment:

Review the performance dashboard metrics in your Assessment 1 Dashboard and Health Care Benchmark Evaluation activity, as well as relevant local, state, and federal laws and policies. Consider the metrics that are falling short of the prescribed benchmarks. Note: The writing you do as part of the simulation could serve as a starting point to build upon for this assessment.

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 and sustainable action to address benchmark underperformance and explain the potential for improving the overall quality of care and performance, as reflected on the performance dashboard.

Make sure your report meets the Report Requirements listed below. Structure it 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.

Report Requirements

The report requirements outlined below correspond to the scoring guide criteria, so be sure to address each main point. Read the performance-level descriptions for each criterion to see how your work will be assessed. In addition, be sure to note the requirements for document format and length and for supporting evidence.

Evaluate dashboard metrics associated with benchmarks set forth by local, state, or federal health care laws or policies.
Which metrics are not meeting the benchmark for the organization?

What are the local, state, or federal health care policies or laws that establish these benchmarks?

What conclusions can you draw from your evaluation?

Are there any unknowns, missing information, unanswered questions, or areas of uncertainty where additional information could improve your evaluation?

Analyze the consequence(s) of not meeting prescribed benchmarks and the impact this has on health care organizations or teams.

Consider the following examples:

Organizational mission and vision.



Financial: Operational and capital funding.

Logistical considerations: Physical space.

Support services (any ancillary department that gives support to a specific care unit in the organization, such as pharmacy, cleaning services, dietary, et cetera).

Cultural diversity in the community.

Staff skills.

Procedures and processes.

Address the following:

What are the challenges that may potentially contribute to benchmark underperformance?

What assumptions underlie your conclusions?

Evaluate a benchmark underperformance in a heath care organization or interprofessional team that has the potential for greatly improving overall quality or performance.

Focus on the benchmark you chose to target for improvement. Which metric is underperforming its benchmark by the greatest degree?

State the benchmark underperformance that is the most widespread throughout the organization or interprofessional team.

State the benchmark that affects the greatest number of patients.

Include how this underperformance will affect the community that the organization serves.

Include the greatest opportunity to improve the overall quality of care or performance of the organization or interpersonal team and, ultimately, to improve patient outcomes, as you think about the issue and the current poor benchmark outcomes.

Advocate for ethical and sustainable action(s), directed toward an appropriate group of stakeholders, needed to address a benchmark underperformance.


Who would be an appropriate group of stakeholders to act on improving your identified benchmark metric?

Why should the stakeholder group take action?

What are some ethical actions the stakeholder group could take that support improved benchmark performance?

Organize content so ideas flow logically with smooth transitions.

Proofread your report, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your evaluation and analysis.

Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.

Be sure to apply correct APA formatting to source citations and references.

Report Format and Length

Format your report using APA style.

Use the APA Style Paper Tutorial [DOCX] to help you in writing and formatting your report. Be sure to include:

A title and references page. An abstract is not required.

Appropriate section headings.

Your report should be 3–5 pages in length, not including the title page and references page.

Supporting Evidence

Cite 4–6 credible sources from peer-reviewed journals or professional industry publications to support your analysis of challenges, evaluation of potential for improvement, and your advocacy for ethical action.

Dashboard and Health Care Benchmark Evaluation

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 a diabetes dashboard and fact sheet used by Mercy Medical Center, a Vila Health affiliated hospital, and determine where the organization is falling short.



Public Health Dashboard – Diabetes

New Patients Last Quarter by Race

African American – 17 (3 percent)

American Indian – 73 (13 percent)

Asian – 34 (6 percent)

White – 355 (63 percent)

Other – 11 (2 percent)

Blank/Declined – 73 (13 percent)

New Patients Last Quarter by Gender

Male – 214 (38 percent)

Female – 347 (62 percent)

Blank/Declined – 2

New Patients Last Quarter by Age

20 or younger – 118 (21 percent)

21-39 – 51 (9 percent)

40-64 – 214 (38 percent)

65+ – 180 (32 percent)

Blank/Declined – 0



Q1 2019 Q2 2019 Q3 2019 Q4 2019 Q1 2020 Q2 2020 Q3 2020 Q4 2020
Eye Exam 50 48 60 42 62 48 58 64
Foot Exam 60 58 42 70 75 50 48 62
HgbA1c 60 48 60 42 72 58 78 64

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 2020 and 2021.

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 percent) 3,822 (10 percent) 2,890 (7 percent) 1,661 (4 percent) 1,601 (4 percent) 1,016 (4 percent) 433 (1 percent)

Shakopee Ledger


Top 20 Workplaces 2020 & 2021

2010 2021
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

Physicians 433
Volunteers (15 — 94 years 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

Now that you’ve reviewed the data answer the following questions:


What are the biggest areas of concern with regards to the information in Mercy Medical Center’s Public Health Dashboard – Diabetes?

Your response:

This question has not been answered yet.

While there are a few areas of concern present in the diabetes public health dashboard, the two biggest areas of concern are the declining HgbA1c exams and the low foot exam rate. Both of these tests are important tests to help identify potential diabetes related complications early.

Some areas that are not concerns, or there is not enough data to say for sure are as follows

The number of eye exams has fluctuated over the last two years. It is about 6 times what it was in first quarter of 2018. and it is four to nine times more than the foot and HgbA1c exams. It could probably be better, but it is not one of the biggest areas of concern.

With regard to the data on new diabetes patients, this dashboard has no information on the total number of new patients in previous quarters. So the new patient numbers cannot definitively be called an issue based on the data available.

Looking at the statement regarding patients aged 20 or younger, similar to the new patient statement, there is not enough data within this dashboard to label it as one of the biggest areas of concern.

Select one of the underperforming metrics. Why and how would improving this metric contribute to the overall success of Mercy Medical Center?


Your response:

This question has not been answered yet.

There is no one right answer for this question. When looking for areas to improve within a care setting it is important to consider factors such as:


The severity of the issue.

The number of patients affected.

Any financial impacts.

Stakeholders involved.

Measureable outcomes.

By building an objective, evidence-based case around these considerations, in addition to any legal or regulatory factors, it is possible to reach a good decision about improvement projects to pursue.


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.

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