revision

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 Eye Exam Foot Exam

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 Male – 25% Female – 25% Total population – 50% Age Group Yellow – 34 % Blue – 42% Grey – 17% Red – 7% Race White – 57% Asian – 8% Hispanic-Latino – 6%. African-American – 3%. Two Races – 2% American-Indian – 1% Other – 23% Shakopee Ledger—Top Workplaces 2020 & 2021 2010 Hospital Rooms (all private) – 42% Medical/Surgical Rooms – 22% Special Care Unit – 5% Family Birth Rooms – 12% Children’s Care Pediatric Rooms – 3% Operating Rooms – 3% Emergency Room Treatment Bays – 11% Endoscopy Room – 1% 2021 Hospital Rooms (all private) – 42% Medical/Surgical Rooms – 28% Special Care Unit – 4% Family Birth Rooms – 8% Children’s Care Pediatric Rooms – 2% Operating Rooms – 4% Emergency Room Treatment Bays – 10% Endoscopy Room – 1% 2021 Physicians – 0% Volunteers – 0% Inpatient Admissions – 2% Surgical Procedures – 2% Births – 0% Emergency Room – 10% Urgent Care Visits – 3% Outpatient Encounters – 39% Physical, Occupational, Speech/Language Therapy Visits – 9% Pediatric Therapy Visits – 4% Sleep Center Visits – 0% Radiology Procedures – 19% Cardiac Rehab Visits – 2% Cardiopulmonary Visits – 6% Cancer Center Visits – 3%

Your revised paper demonstrates considerable improvement, but there are still some areas that need attention to fully address the faculty comments and meet the competencies. Below are specific comments on each section based on the feedback provided by your faculty.

Competency 1: Analyze relevant health care laws, policies, and regulations

· Consequence(s) of not meeting prescribed benchmarks: Your revised paper needs more specific analysis of the consequences of not meeting diabetic care benchmarks beyond patient health outcomes. Consider organizational consequences such as potential financial penalties, loss of accreditation, reduced reimbursement rates, and damage to the organization's reputation. Including evidence from the literature would strengthen this section. For instance, you could cite studies that show the financial and reputational impacts on healthcare organizations failing to meet specific benchmarks.

Competency 2: Lead the development and implementation of ethical and culturally sensitive policies

· Ethical and sustainable actions: This section is strong, effectively advocating for ethical and sustainable actions. You've directed these recommendations toward appropriate stakeholders and provided clear explanations of the ethical principles and sustainability goals.

Competency 3: Evaluate relevant indicators of performance

· Dashboard metrics associated with benchmarks: While you have started to address this, the section still lacks specific benchmarks set forth by local, state, or federal health care laws or policies. You need to include a more detailed evaluation of how Mercy Medical Centre's performance compares to these specific benchmarks. For example, mention specific CMS or HEDIS requirements and how Mercy Medical Centre falls short or meets these standards, citing relevant sources.

· Evaluation of benchmark underperformance: Elaborate more on both components of the benchmarks (e.g., HgbA1c levels, eye exams, foot exams) and how they reflect on the healthcare organization’s performance. Discuss how failing to meet these benchmarks affects the organization’s financial health, patient trust, and overall operational efficiency. Citing authoritative sources that discuss the implications of not meeting these benchmarks would add depth to your analysis.

Competency 5: Produce clear, coherent, and professional written work

· Organize content with logical flow and smooth transitions: Your paper still needs clear headers for each section as per APA standards. This will help in organizing the content and ensuring smooth transitions between sections. Consider the following structure:

1. Introduction

2. Diabetes Care Benchmarking

3. Consequences of Not Meeting Benchmarks

4. Analysis of Benchmarks Provided by Laws or Policies

5. Performance Evaluation Against Benchmarks

6. Staffing and Training Needs

7. Recommendations

8. Conclusion

· Support main points with credible evidence: While you have incorporated citations, ensure that all sources are credible and relevant. Make sure to adhere strictly to APA formatting, including correct capitalization and spacing in the reference list, and ensure all journal titles are formatted correctly. Including DOIs or URLs for all sources is essential.

Here’s an example of how you could revise a specific section to meet the comments:

Consequence(s) of not meeting prescribed benchmarks: "Failure to meet diabetic care benchmarks can lead to several adverse consequences for healthcare organizations like Mercy Medical Centre. For example, non-compliance with CMS's diabetes management measures can result in reduced reimbursement rates and financial penalties (Wadhera et al., 2020). Additionally, poor performance on key indicators can damage the organization’s reputation, leading to a loss of patient trust and a decline in patient referrals (Kharazishvili et al., 2020). Moreover, failing to meet these benchmarks may jeopardize the facility's accreditation status, as regulatory bodies require adherence to certain standards to maintain accreditation (Narayan et al., 2024). These consequences highlight the critical need for MMC to improve its performance to avoid financial and reputational damage."

Conclusion: Your conclusion is thorough, but consider removing the separate "Conclusion" header as per the faculty’s APA formatting feedback. Instead, integrate this section as part of the "Recommendations" to maintain a smooth flow and clear structure.

By incorporating these changes and adding specific, evidence-based analyses and clear organizational headers, your paper will more effectively meet the faculty's expectations and competencies.

1

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