FPX 6004 Course Assessments week 1-3 Assignments

 FPX 6004 Course Assessments week 1-3 Assignments
 FPX 6004 Course Assessments week 1-3 Assignments
 FPX 6004 Assessment 1 Dashboard Metrics Evaluation Paper
Assessment 1 Instructions: Dashboard Metrics Evaluation Paper 
Dashboard Metrics Evaluation
To the Director of Safety Compliance
Benchmark evaluation is a tool used to measure organizational outcomes and performance and identify areas that require improvement. Organizational dashboard metrics are used to gauge the organization’s performance based on the available benchmarks, thus identifying well-performing and underperforming metrics, therefore informing quality improvement initiatives and interventions. I have reviewed and evaluated an institution’s compliance with set diabetes measures using the institution’s dashboard data and identified performing and underperforming benchmarks. This report presents an evaluation of the diabetes dashboard data of Mercy Medical Center. The report will entail evaluating the benchmark data, challenges in meeting the benchmark can pose to the organization, benchmark underperformance areas, areas that the institution needs to improve, and a proposal for an ethical action that stakeholders can use in the organization to improve benchmark underperformance.
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Organizational and Setting Description
The institution of focus in this evaluation is Mercy Medical Center. It is a Villa health-affiliated hospital located in Shakopee, Minnesota. The institutions serve over 30,000 patients from different races across all health populations. It is a top-choice healthcare institution renowned for high healthcare quality. Some of the most common races of patients served in the institution include Asians, Whites, Hispanics-Latinos, and African Americans. The specific department that will be evaluated is the endocrinology department. The benchmarks of focus will include data regarding diabetes in the institution.

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Evaluation of Dashboard Metrics
According to the institution’s public health dashboard-in diabetes, 563 new diabetes patients were served in the last quarter of 2020. The factors essential in diabetes management include age, gender, and race. The diabetic patients’ age distribution is 118 patients who are 20 years and below, 51 patients between ages 21-39, 214 patients between ages 40-64, and 180 patients 65 years and above. The percentages for this distribution are 21%, 9%, 38%, and 32% for ages, respectively (Villa Health, n.d.). The patients’ distribution by gender is 214 males, 38%, and 347 females 62%. The distribution by race is as follows; African Americans-3%, American Indians-13%, Asians-6%, Whites 63%, and others-2%, while 13% of the patients declined to provide their racial background (Villa Health, n.d).
Furthermore, the institution has set forth measures of effective diabetes management, which are also used to gauge the organizational performance and quality of healthcare services. Diabetes interventions and measures include eye exams, diabetic foot exams, and HbA1c tests. These measures are evaluated quarterly. From the dashboard, it is noted that the number of patients taking these tests fluctuates significantly. For instance, in the last quarter of 2020, out of 563 patients, only 64, 64, and 62 patients took the HbA1c tests, Eye exams, and Foot exams, respectively.
Benchmarks Set Forth by the Local, State or Federal Laws/Policies 
Mercy Medical Center is keen on internal and external benchmarking, in which the results are used to facilitate learning, quality improvement, and performance evaluation. According to De Rosis, Cerasuolo & Nuti (2020), an internal benchmarking tool may include patients reported measures and compare performance measures in different timelines, such as different quarters, to identify in which quarter the institution did better than the other. External benchmarking is also done using local, state, and federal laws and policies to inform practice improvement and align the institution’s activities with contributing towards meeting healthcare needs.
The Agency for Healthcare Research and Quality is one of the organizations the institution uses for external benchmarking. The agency works with the government and other associations, such as the American diabetes association, to prepare benchmark tools and strategies used as benchmark evaluation dashboards. These dashboards aim to direct healthcare institutions and systems to provide high-quality care, promote patient safety, and maintain values in healthcare services (AHRQ, n.d.). The AHRQ prepares and releases a National Healthcare Quality and Disparities report annually, which Mercy Medical Center also uses as an external benchmark tool. The report not only the current health disparities in healthcare among various populations but also provides recommendations on the various measures to ensure desirable patient outcomes in different health conditions. For instance, the AHQR notes that the current national health quality and disparities report of 2019 recommended that above 80% of diabetes patients take HbA1c tests annually, above 84% g for diabetes foot exams, and 75% go for eye exams annually (AHRQ, n.d.). However, gauging from the percentages of patients going for diabetic foot exams and eye exams and taking HbA1c tests in the institution annually, it is evident that the institution is performing below the prescribed benchmarks. One of the areas of uncertainty in the evaluation is that the data does not provide specific patient characteristics such as age, gender, and ethnicity for the patients going for diabetic foot exams, eye exams, and taking HbA1c tests. The information would improve evaluation results and better inform improvement initiatives by identifying the specific group of patients to focus on.  
Consequences of not meeting Prescribed Benchmarks
Not meeting the prescribed benchmarks has various consequences, considerably impacting healthcare organizations and teams. According to Wong et al. (2020), healthcare institutions that cannot meet prescribed benchmarks may face quality and reputation problems. Since performance is described from some benchmark evaluations, failure to meet them translates to poor performance, which may negatively affect the organization’s reputation. According to De Silva et al. (2021), other implications of failure to meet the benchmark include demotivation of the healthcare team. Challenges that might have contributed to benchmark underperformance are inadequate emphasis on diabetes health promotion and patient education to inform the patients on the importance of eye, diabetic foot exams, and HbA1c tests to keep track of their progress and prevent complications.
Benchmark Underperformance Evaluation
The primary benchmark underperformance in this evaluation is the low turn-up for diabetic foot exams, eye exams, and HbA1c tests. These tests are significant to diabetes patients since they help identify diabetes complications early enough and address them as soon as possible (Nano et al., 2020). The benchmark underperformance negatively impacts the health of patients and the community due to increased diabetes complications, diabetes-related hospitalizations, and hospital readmissions. The healthcare team can use this underperformance as an improvement opportunity to promote health and educate diabetic patients, thus enhancing diabetes management and preventing complications.
Ethical and Sustainable Action Required to Address the Benchmark Underperformance
The essence of benchmark evaluations is seen when they are followed up with ethical and sustainable actions to address identified benchmark underperformances. The stakeholders addressing the benchmark underperformances for Mercy Medical Center include endocrinologists, nurses, dieticians, social workers, and community health workers. These stakeholders will address the benchmark underperformances by encouraging diabetes patients to embrace diabetes management best practices, including going for annual eye exams, diabetic food exams, and taking HbA1c tests. The ethical principles of consideration in action include confidentiality and privacy in patient education. The sustainable goal for the benchmark underperformance is a maintained increased number of patients taking HbA1c tests and going for eye and diabetic foot exams annually.                 
Conclusion
            The report above has helped us understand the performance of Mercy Medical Center against the set benchmarks. It shows that the institution is underperforming in some critical areas, such as the number of patients taking diabetes foot exams. The report has also proposed an ethical action that can be used to address the underperforming benchmark. The stakeholders identified should work towards improving the underperforming benchmarks and therefore improve care delivery for diabetes patients.              
References
Agency for Healthcare Research and Quality, (n.d). Practice Improvement. Retrieved 14th March 2023 from https://www.ahrq.gov/practiceimprovement/index.html
De Rosis, S., Cerasuolo, D., & Nuti, S. (2020). Using patient-reported measures to drive change in healthcare: the experience of the digital, continuous and systematic PREMs observatory in Italy. BMC Health Services Research, 20, 1–17. https://doi.org/10.1186/s12913-020-05099-4
 De Silva, K., Lim, S., Mousa, A., Teede, H., Forbes, A., Demmer, R. T., Jönsson, D., & Enticott, J. (2021). Nutritional markers of undiagnosed type 2 diabetes in adults: Findings of a machine learning analysis with external validation and benchmarking. PloS One, 16(5), e0250832. https://doi.org/10.1371/journal.pone.0250832
Nano, J., Carinci, F., Okunade, O., Whittaker, S., Walbaum, M., Barnard-Kelly, K., Barthelmes, D., Benson, T., Calderon-Margalit, R., Dennaoui, J., Fraser, S., Haig, R., Hernández-Jimenéz, S., Levitt, N., Mbanya, J. C., Naqvi, S., Peters, A. L., Peyrot, M., Prabhaharan, M., Pumerantz, A. & Diabetes Working Group of the International Consortium for Health Outcomes Measurement (ICHOM) (2020). A standard set of person-centered outcomes for diabetes mellitus: results of an international and unified approach. Diabetic medicine: a journal of the British Diabetic Association, 37(12), 2009–2018. https://doi.org/10.1111/dme.14286
Villa Health. (n.d). Dashboard and Healthcare Benchmark Evaluation. Capella University.
Wong, T., Brovman, E. Y., Rao, N., Tsai, M. H., & Urman, R. D. (2020). A Dashboard Prototype for Tracking the Impact of Diabetes on Hospital Readmissions Using a National Administrative Database. Journal of Clinical Medicine Research, 12(1), 18–25. https://doi.org/10.14740/jocmr4029
 
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Write a 3-5 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 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. Understanding 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.
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.
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 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 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

 
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. Resources.
Staffing.
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.
Portfolio Prompt: You may choose to save your report to your ePortfolio.
 
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
Competency 1: Analyze relevant health care laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
Analyze the consequence(s) of not meeting prescribed benchmarks and the impact this has on health care organizations or teams.
Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that
improve health outcomes for individuals, organizations, and populations.
Advocate for ethical and sustainable action(s), directed toward an appropriate group of stakeholders, needed to address a benchmark underperformance.
Competency 3: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, to inform health care laws and policies for patients, organizations, and populations.
Evaluate dashboard metrics associated with benchmarks set forth by local, state, or federal health care
laws or policies.
Evaluate a benchmark underperformance in a health care organization or interprofessional team that has the potential for greatly improving quality or performance.
Competency 5: Produce clear, coherent, and professional written work, in accordance with Capella’s writing standards.
Organize content so ideas flow logically with smooth transitions.
Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.
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SCORING GUIDE
Use the scoring guide to understand how your assessment will be evaluated.
VIEW SCORING GUIDE
Dashboard Metrics Evaluation Scoring Guide

CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED

Evaluate dashboard
Does not evaluate
Evaluates dashboard
Evaluates dashboard
Provides an objective,

metrics associated
dashboard metrics
metrics not clearly
metrics associated
accurate evaluation of

with benchmarks set
associated with
associated with
with benchmarks set
dashboard metrics

forth by local, state,
benchmarks set forth
benchmarks set forth
forth by local, state,
associated with

or federal health
by local, state, or
by local, state, or
or federal health care
benchmarks set forth

care laws or
federal health care
federal health care
laws or policies.
by local, state, or

policies.
laws or policies.
laws or policies,

federal health care laws

leading to

or policies. Clearly

unsubstantiated

articulates

conclusions about

organizational

organizational

performance shortfalls

performance.

and any gaps in

information affecting

the evaluation.

Analyze the
Does not identify the
Identifies the
Analyzes the
Analyzes the

consequence(s) of
consequence(s) of
consequence(s) of not
consequence(s) of
consequence(s) of not

not meeting
not meeting
meeting prescribed
not meeting
meeting prescribed

prescribed
prescribed
benchmarks and the
prescribed
benchmarks and the

benchmarks and the
benchmarks and the
impact this has on
benchmarks and the
impact this has on

impact this has on
impact this has on
health care
impact this has on
health care

health care
health care
organizations or
health care
organizations or teams.

organizations or
organizations or
teams.
organizations or
Identifies clear

teams.
teams.

teams.
implications of such

consequences for the

organization or team

and acknowledges

assumptions underlying

the analysis.

Evaluate a
Does not evaluate a
Conducts an
Evaluates a
Evaluates a benchmark

benchmark
benchmark
evaluation of a
benchmark
underperformance in a

underperformance
underperformance in
benchmark
underperformance in
heath care organization

in a health care
a heath care
underperformance in a
a heath care
or interprofessional

organization or
organization or
heath care
organization or
team that has the

interprofessional
interprofessional
organization or
interprofessional
potential for greatly

team that has the
team that has the
interprofessional team
team that has the
improving overall

potential for greatly
potential for greatly
that misinterprets or
potential for greatly
quality or performance.

improving quality or
improving overall
overlooks factors that
improving overall
Provides a compelling

performance.
quality or
are key to a clear
quality or
and fully substantiated

performance.
understanding of the
performance.
argument for the

potential for improving

chosen benchmark’s

overall quality or

potential impact on

performance.

quality of performance.

Advocate for ethical
Does not advocate
Advocates for ethical
Advocates for ethical
Advocates for ethical

and sustainable
for ethical and
and sustainable
and sustainable
and sustainable

action(s), directed
sustainable action(s)
action(s) needed to
action(s), directed
action(s), directed

toward an
needed to address a
address a benchmark
toward an
toward an appropriate

appropriate group of
benchmark
underperformance.
appropriate group of
group of stakeholders,

stakeholders,
underperformance.

stakeholders,
needed to address a

needed to address a

needed to address a
benchmark

benchmark

benchmark
underperformance.

underperformance.

underperformance.
Argues effectively for

recommended actions

underscored by a clear

and perceptive

explanation of the

CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
ethical principles and sustainability goals to guide such actions.

Organize content so ideas flow logically with smooth transitions.
Does not organize content for ideas to flow logically with smooth transitions.
Organizes content with some logical flow and smooth transitions.
Organizes content so ideas flow logically with smooth transitions.
Organizes content so clarity is enhanced and all ideas flow logically with smooth transitions.

Support main
Does not support
Does not support main
Supports main
Supports main points,

points, assertions,
main points,
points, assertions,
points, assertions,
assertions, arguments,

arguments,
assertions,
arguments,
arguments,
conclusions, or

conclusions, or
arguments,
conclusions, or
conclusions, or
recommendations with

recommendations
conclusions, or
recommendations with
recommendations
relevant, credible, and

with relevant and
recommendations
relevant and credible
with relevant and
convincing evidence.

credible evidence.
with relevant and
evidence.
credible evidence.
Skillfully combines

credible evidence.

virtually error-free

source citations with a

perceptive and

coherent synthesis of

the evidence.

NHS-FP6004 Assessment 2 Policy Proposal
NHS-FP6004 Assessment 2 Policy Proposal

Draft a written proposal and implementation guidelines for an organizational policy that you believe would help lead to an improvement in quality and performance associated with the benchmark metric for which you advocated action in Assessment 1.
Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.
In advocating for institutional policy changes related to local, state, or federal health care laws or policies, health leaders must be able to develop and present clear and well-written policy and practice guidelines change proposals that will enable a team, unit, or the organization as a whole to resolve relevant performance issues and bring about improvements in the quality and safety of health care. This assessment offers you an opportunity to take the lead in proposing such changes.
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Assessment Instructions for NHS-FP6004 Assessment 2 Policy Proposal
In this assessment, you will build on the dashboard benchmark evaluation work you completed in Assessment 1.
PREPARATION
After reviewing your benchmark evaluation, senior leaders in the organization have asked you to draft a policy change proposal and practice guidelines addressing the benchmark metric for which you advocated action.
In their request, senior leaders have asked for a proposal of not more than 2–4 pages that includes a concise policy description (about one paragraph), practice guidelines, and 3–5 credible references to relevant research, case studies, or best practices that support your analysis and recommendations. You are also expected to be precise, professional, and persuasive in justifying the merit of your proposed actions.
When creating your policy and guidelines it may be helpful to utilize the template that your current care setting or organization uses. Your setting’s risk management or quality department could be a good resource for finding an appropriate template or format. If you are not currently in practice, or your care setting does not have these resources, there are numerous appropriate templates freely available on the Internet.
PROPOSAL REQUIREMENTS for NHS-FP6004 Assessment 2 Policy Proposal
Note: The tasks outlined below correspond to grading criteria in the scoring guide.
In your proposal, senior leaders have asked that you:

Explain why a change in organizational policy or practice guidelines is needed to address a shortfall in meeting a performance benchmark prescribed by applicable local, state, or federal health care laws or policies.

What is the current benchmark for the organization? What is the numeric score for the underperformance?
How might the benchmark underperformance be affecting the quality of care being provided or the operations of the organization?
What are the potential repercussions of not making any changes?

Recommend ethical, evidence-based strategies to resolve the performance issue.

What does the evidence-based literature suggest are potential strategies to improve performance for your targeted benchmark?
How would these strategies ensure improved performance or compliance with applicable local, state, or federal health care laws or policies?
How would you propose to apply these strategies in the context of your chosen professional practice setting?
How would you ensure that the application of these strategies is ethical and culturally inclusive?
Does your policy encompass the key components of your recommendations?

Analyze the potential effects of environmental factors on your recommended strategies.

What regulatory considerations could affect your recommended strategies?
What organizational resources could affect your recommended strategies (for example, staffing, finances, logistics, and support services)?
Are your policy and guidelines realistic in light of existing environmental factors?

Propose a succinct policy and guidelines to enable a team, unit, or the organization as a whole to implement recommended strategies to resolve the performance issue related to the relevant local, state, or federal health care policy or law.
Identify colleagues, individual stakeholders, or stakeholder groups who should be involved in further development and implementation of your proposed policy, guidelines, and recommended strategies.

Why is it important to engage these colleagues, individual stakeholders, or stakeholder groups?
Do your proposed guidelines help colleagues, individual stakeholders, or stakeholder groups understand how to implement your proposed policy?
How might engaging these colleagues, individual stakeholders, or stakeholder groups result in a better organizational policy and smoother implementation?
Are your proposal and recommended strategies rea