Capella University

NHS-FPX 6004: Health Care Law and Policy

February, 2024

NHS-FPX 6004 Assessment 1

Dashboard Metrics Evaluation

In modern healthcare, providing safe and high-quality care to patients is a top priority. Mercy Medical Center, a member of the Villa Health network, is dedicated to achieving excellence in patient outcomes. One way they do this is by using health dashboards, which help them analyze healthcare data and evaluate their performance. This paper will focus on the diabetes dashboards that Mercy Medical Center uses. These dashboards are not just a collection of data; they are complex analytical tools that provide real-time insights into patient outcomes, care quality, and operational efficiency. By understanding the information presented in these dashboards, Mercy Medical Center can align its practices with national and local healthcare standards (Alvarado et al., 2021).

The data presented by the diabetes dashboards and evaluate it against existing policies and benchmarks. The standards set forth by authoritative healthcare bodies determine how Mercy Medical Center’s performance measures up in this critical area of patient care. The consequences of falling short of prescribed benchmarks were examined, recognizing that non-compliance has real implications for patient care and institutional integrity. Finally, ethical and practical interventions were proposed to improve performance and embed a culture of continuous improvement and ethical responsibility within the institution. Through this comprehensive approach, Mercy Medical Center aims to exceed the standards of care and deliver exceptional healthcare services.

Dashboard Metrics Evaluation Simulation 

This report evaluates a healthcare organization’s compliance with healthcare laws and policies by comparing its performance against established benchmarks. Patient satisfaction, readmission rates, and adherence to treatment protocols are some performance metrics considered (Song & Chamber, 2023). The report identifies gaps in patient experience and inefficiencies in discharge planning, suggests targeted improvements, and emphasizes the importance of continuous evaluation to ensure alignment with healthcare quality and patient safety standards.

Hospital Dashboard Metrics Evaluation

In a healthcare setting, the use of hospital dashboards for performance evaluation is not just a trend but a necessity for maintaining high standards of patient care. This report evaluates the dashboard metrics of a healthcare facility serving over 20,000 patients across various demographics, including reproductive health, emergency and critical care, theater, and outpatient care services (Jia et al., 2022). The dashboard is evaluated quarterly, comparing current performance to previous years or quarters, with data segmented by age and race. The primary health indicators of interest are HbA1c tests and Diabetic foot examinations, crucial metrics for managing and monitoring diabetes. In the last quarter, Diabetic foot examinations were at 62%, and HbA1c tests were at 64%, a significant drop from the previous quarter’s 78%. The healthcare facility must investigate the underlying causes and implement targeted interventions to improve these metrics, reinforcing its commitment to delivering exemplary healthcare services across all demographics.

Evaluating Healthcare Performance in Accordance with AHRQ Benchmarks: A Simulation Report for Senior Leadership

This report evaluates our organization’s performance in diabetes care by analyzing data from the Assessment 1 Dashboard and Health Care Benchmark Evaluation. The AHRQ sets benchmarks for healthcare organizations, including metrics such as HgbA1c tests, diabetic foot tests, and annual eye exams for diabetic patients. Our evaluation shows gaps in diabetic foot tests and eye exams, which could lead to health risks and negative implications for our reputation and compliance. We propose improving staff training, enhancing patient education, and investing in efficient data tracking to address these gaps. By improving diabetic foot examinations, we can reduce treatment costs and hospital readmissions and improve patient quality of life. Aligning with AHRQ benchmarks is crucial for healthcare organizations’ ongoing success and viability.

Consequences of Not Meeting Prescribed Healthcare Benchmarks

Adhering to prescribed benchmarks in the healthcare sector is critical for regulatory compliance and ensuring quality patient care. Failure to meet these benchmarks can seriously affect healthcare organizations and their teams. This analysis examines the underperformance implications and the underlying assumptions that shape our understanding of these impacts. The most immediate and concerning consequence of not meeting benchmarks is the potential decline in patient care and safety (Helminski et al., 2022). For instance, if a hospital fails to meet its diabetic foot examination rates, patients are at a higher risk of undetected complications, leading to worse health outcomes. This direct impact on patient health and safety is a primary concern and reflects the core mission of healthcare institutions.

Non-compliance with benchmarks can also result in financial penalties and legal actions, which can strain the organization’s financial health. Reduced reimbursement rates from insurance providers, fines, and the cost of legal defense can significantly impact the organization’s bottom line (Helminski et al., 2022). This financial burden might lead to budget cuts in critical areas, further affecting patient care. Public perception is crucial in healthcare. Not meeting benchmarks can tarnish an organization’s reputation, losing trust among patients and the community. This reputational damage can result in a decline in patient numbers, difficulty recruiting top talent, and challenges in forming partnerships with other healthcare entities.

Falling within healthcare benchmarks can demotivate healthcare teams, increase staff turnover, and lead to challenges in maintaining high standards of care. Poor performance may result in increased scrutiny by regulatory bodies, difficulties maintaining necessary accreditations, and even the risk of losing the operating license. It is important to note that meeting benchmarks assumes that healthcare organizations have the necessary resources and capabilities to comply. Not meeting healthcare benchmarks affects patient care, financial stability, reputation, staff morale, and regulatory standing (Graham et al., 2023). Healthcare organizations must recognize and address these consequences to maintain high-quality patient care. It is also crucial to continuously evaluate the feasibility and relevance of these benchmarks to ensure they align with the evolving healthcare landscape.

Evaluating the Impact of Benchmark Underperformance on Healthcare Quality

This report analyzes the benchmark of diabetic foot examination rates in healthcare settings, which is critical for managing and monitoring diabetes patients. Our current diabetic foot examination rates fall below the prescribed benchmark, which can lead to an increased risk of foot complications, higher hospitalization rates, and greater healthcare costs. Improving these rates can significantly reduce the risk of severe outcomes, enhance patient outcomes and satisfaction, and reduce healthcare costs (Cocksey, 2022). To address this, staff training on the importance of foot examinations, integrating reminders into electronic health records, patient education programs, and a cultural shift within the organization to prioritize preventive care in chronic disease management are required. By prioritizing this benchmark, our organization can take a substantial step towards excellence in healthcare delivery and patient satisfaction.

Advocating for Ethical and Sustainable Actions to Address Benchmark Underperformance in Diabetic Foot Examination Rates

In the healthcare sector, improving the benchmark performance of diabetic foot examinations requires ethical and sustainable practices. A multi-stakeholder approach is necessary to engage healthcare providers, administrative staff, patients, and policymakers. Healthcare providers need education and training to improve their understanding and skills in conducting diabetic foot examinations. This will improve care quality, align with the ethical principle of beneficence, and prevent potential harm from unmanaged diabetic conditions, adhering to the principle of non-maleficence. Administrative staff must integrate these practices into the healthcare system by implementing changes such as electronic medical record prompts for diabetic foot examinations (Randell et al., 2022). This ensures consistency in care delivery and embeds the practice into the organizational culture, making it a sustainable change. Patient education is also critical to empower them to take an active role in their healthcare management. Informing patients about the importance of regular foot examinations encourages a more collaborative healthcare experience and ensures that all patients receive equitable care, addressing the ethical principle of justice.

Advocacy at the policy level is essential to support and sustain these changes. Lobbying for policies that facilitate regular diabetic screenings and allocate resources, particularly in underserved areas, can help maintain these improved care standards over the long term. In summary, the recommended actions for addressing the underperformance in diabetic foot examinations are multifaceted and target various stakeholders in the healthcare system. By focusing on education, system integration, patient empowerment, and policy advocacy, these actions uphold the principles of beneficence, non-maleficence, justice, and autonomy, ensuring that the improvement in care quality is both morally sound and enduring (Randell et al., 2022). 


To address the low rates of diabetic foot examinations in healthcare settings, it is important to work together ethically and sustainably. By engaging healthcare providers, administrative staff, patients, and policymakers, we can improve patient care (Helminski et al., 2022). This can be achieved through education and training for healthcare providers, system integration by administrative staff, patient education and empowerment, and policy advocacy. This approach meets the immediate need to enhance care quality and aligns with core ethical principles, ensuring that the healthcare organization maintains high standards of patient care and safety. A holistic and ethical approach like this is essential for healthcare improvements’ long-term success and sustainability.


Alvarado, N., McVey, L., Elshehaly, M., Greenhalgh, J., Dowding, D., Ruddle, R., Gale, C. P., Mamas, M., Doherty, P., West, R., Feltbower, R., & Randell, R. (2021). Analysis of a web-based dashboard to support the use of national audit data in quality improvement: realist evaluation. Journal of Medical Internet Research, 23(11), e28854. https://doi.org/10.2196/28854

Cooksey C. (2020). Strategies to improve annual diabetic foot screening compliance at a family clinic. clinical diabetes:American Diabetes Association, 38(4), 386–389. https://doi.org/10.2337/cd20-0030

Graham, K., Siatis, C. M., Gunn, K. M., Ong, E., Loughry, C., McMillan, N., & Fitridge, R. (2023). The experiences of health workers using telehealth services for diabetes-related foot complications: a qualitative exploration. Journal of Foot and Ankle Research, 16(1), 47. https://doi.org/10.1186/s13047-023-00645-9

Helminski, D., Kurlander, J. E., Renji, A. D., Sussman, J. B., Pfeiffer, P. N., Conte, M. L., Gadabu, O. J., Kokaly, A. N., Goldberg, R., Ranusch, A., Damschroder, L. J., & Landis-Lewis, Z. (2022). Dashboards in health care settings: protocol for a scoping review. JMIR Research Protocols, 11(3), e34894. https://doi.org/10.2196/34894

Jia, H., Wang, X., & Cheng, J. (2022). Knowledge, attitudes, and practices associated with diabetic foot prevention among rural adults with diabetes in north china. Frontiers in Public Health, 10, 876105. https://doi.org/10.3389/fpubh.2022.876105

Randell, R., Alvarado, N., Elshehaly, M., McVey, L., West, R. M., Doherty, P., Dowding, D., Farrin, A. J., Feltbower, R. G., Gale, C. P., Greenhalgh, J., Lake, J., Mamas, M., Walwyn, R., & Ruddle, R. A. (2022). Design and evaluation of an interactive quality dashboard for national clinical audit data: a realist evaluation. National Institute for Health and Care Research.

Song, K., & Chambers, A. R. (2023). Diabetic Foot Care. In StatPearls. StatPearls Publishing.

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