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.

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Write a 4-6-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 addition, advocate for ethical action to address benchmark underperformance and explain the potential for improving the overall quality of care and performance, as reflected on a performance dashboard.
Introduction
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. An understanding of 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.
Note: Your evaluation of dashboard metrics for this assessment is the foundation on which all subsequent assessments are based. Therefore, you must complete this assessment first.
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 action to address benchmark underperformance and explain the potential for improving the overall quality of care and performance, as reflected on a performance dashboard.
Review the performance dashboard metrics, as well as relevant local, state, and federal laws and policies. Consider the metrics that are falling short of the prescribed benchmarks. Structure your report 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.
Note: Remember that you can submit all, or a portion of, your draft report to Smarthinking for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.
Preparation
Choose one of the following three options for a performance dashboard to use as the basis for your evaluation:
Option 1: Dashboard Metrics Evaluation Simulation
Use the data presented in the Dashboard and Health Care Benchmark Evaluation multimedia activity as the basis for your evaluation.
Note: The writing that 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.
Option 3: Hypothetical Dashboard
If you have a sophisticated understanding of dashboards relevant to your own practice, you may also construct a hypothetical dashboard for your evaluation. Your hypothetical dashboard must present at least four different metrics, at least two of which must be underperforming the prescribed benchmark set forth by a federal, state, or local laws or policies. In addition, 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 HIPAA compliant. Do not use any easily identifiable organization or patient information.
Instructions
Note: Your evaluation of dashboard metrics for this assessment is the foundation on which all subsequent assessments are based. Therefore, you must complete this assessment first.
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 action to address benchmark underperformance and explain the potential for improving the overall quality of care and performance, as reflected on a performance dashboard.
Review the performance dashboard metrics, as well as relevant local, state, and federal laws and policies. Consider the metrics that are falling short of the prescribed benchmarks. Structure your report 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.
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 one challenge that meeting prescribed benchmarks can pose for a heath care organization or interprofessional team.
Consider the following examples:
Strategic direction.
Organizational mission.
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 organization and community.
Procedures and processes.
Address the following:
Why do the challenges you identified contribute, potentially, 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. Which benchmark affects the greatest number of staff?
Include how this underperformance 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 action, directed toward an appropriate group of stakeholders, 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.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:
Assessment 1 Example [PDF].
Report Format and Length
Format your report using APA style.
Use the APA Style Paper Template [DOCX]. An APA Style Paper Tutorial [DOCX] is also provided to help you in writing and formatting your report. Be sure to include:
A title page and references page. An abstract is not required.
A running head on all pages.
Appropriate section headings.
Be sure your report is 4–6 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.
Note: Faculty may use the Writing Feedback Tool when grading this assessment. The Writing Feedback Tool is designed to provide you with guidance and resources to develop your writing based on five core skills. You will find writing feedback in the Scoring Guide for the assessment, once your work has been evaluated.
Portfolio Prompt: You may choose to save your report to your ePortfolio.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment 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 challenges that meeting prescribed benchmarks can pose for a heath care organization or interprofessional team.
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 action, directed toward an appropriate group of stakeholders, 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 heath care organization or interprofessional team that has the potential for greatly improving overall 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.
Here’s an example paper:
Sepsis Dashboards from Eagle Creek Hospital
(Learners: You do not have to include charts like these in your report.)
Third Quarter Sepsis Intervention Compliance
at Eagle Creek Hospital for Adults Presenting with Sepsis
Intervention
Needed
Completed
Compliance Percentage
Initial lactate within 3 hours
Blood cultures drawn prior to antibiotics
Antibiotics administered within 3 hours
Fluid resuscitation if in septic shock within 3 hours
Vasopressors if hypotension persists after fluid resuscitation or lactate > 4mmoL/L within 6 hours
27 27
27 19
27 24
17 15
10 6 108 91
100% 70% 89%
88%
60% 84%
0 1
0 0 1 1 1 0 0 0
Overall
1000 3 1009 4
1014 5 1017 5 1060 3 1074 5 1084 4 1087 5 1094 3 1106 4
2 4
5 5 1 4 2 5 3 4
Third Quarter Sepsis Intervention Compliance and Inpatient Mortality (Sample)
Patient ID
# of Interventions Needed
# of Interventions Completed
Inpatient Mortality
Note: The staffing benchmark for nurse staffing in this unit is 2 patients per nurse. Monthly average staffing for the unit is 2 nurse workload units. The average number of patients in the unit per month in the third quarter was 6.75.
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To the Director of Safety Compliance:
I have reviewed the data that you sent my way regarding our compliance with sepsis measures and intervention compliance, plus the sample of our third quarter inpatient mortality. The following contains my evaluation of the data, which shows that there are definitely areas that the organization needs to improve, as well as a proposal for a specific area and target for improvement.
Evaluation of dashboard metrics
There are numerous underperformances in the metrics regarding compliance for sepsis measures at Eagle Creek Hospital. From the dashboard regarding compliance of performing the prescribed measures and procedures, the two that stand out are the 70% compliance rate on drawing blood cultures prior to administering antibiotics, and the 60% compliance rate on administering vasopressors for those patients that require them. According to Medicare.Gov (n.d.) the national average for meeting the Sepsis bundle guidelines is 60% and the state of Minnesota is 57% thus indicating Eagle Creek is performing well at 84% total testing. But higher percentages are needed to help ensure an improved quality of life for residents of
the facility.
In the case of failing to complete blood draws for cultures prior to administering broad- spectrum antibiotics, this creates a risk that there will be an inability to confirm infection and the responsible pathogen (Dellinger et al., 2013). This could result in inefficient or ineffective interventions for helping a patient. Further, by failing to confirm infection from the start, unnecessary and wasteful care interventions could be performed or ordered for patients.
In the case of the failure to administer vasopressors, we are truly gambling with the lives of our patients. As the Surviving Sepsis Campaign reinforces, “vasopressor therapy is required to sustain life and maintain perfusion in the face of life-threatening hypertensions” (Dellinger et al., 2013). The essential nature of compliance with regard to administering this intervention can be seen in our sample of data regarding compliance and inpatient mortality. Of
3
the four patients that required vasopressors to be administered, three received them and one did not. The one that did not passed away. A benchmarking study that included patient data from 2004 to 2009 found that the in-hospital mortality ranged from 14.7% to 29.9% (Gaieski et al., 2013). Based on our sample data, Eagle Creek Hospital has a 40% mortality rate. This is unacceptable, even in a small data sample.
Analysis of challenges in achieving acceptable performance
There are two main challenges facing the organization and the care unit primarily responsible for care of adult patients presenting with sepsis. The first issue is that the unit was understaffed throughout the third quarter. On a per-month average basis during the third quarter, the unit was understaffed by 1.375 nurse workload units. This is problematic from the standpoint that interventions may not have been performed because of the lack of appropriate staffing. Additionally, from an ACA compliance standpoint, we have not been staffing at the mandated benchmark for the unit. I understand that hiring additional staff poses its own logistical and financial challenges. However, it appears that additional staffing is required for this care unit. It is either that or we will need to start diverting patients to other care facilities, which could compound any financial challenges already faced by our organization.
The second challenge, which is also a potential cause of sepsis interventions not being appropriately administered, is that Eagle Creek Hospital does not have currently have a formalized policy or practice guidelines for any of our care providers at any level of the organization. There is an understanding that the Society of Critical Care Medicine has produced the definitive guidelines for practice around treating adult sepsis (Society of Critical Care Medicine, n.d.). However, there are no policies or procedures for how people within Eagle Creek should be applying these resources to their practice. Guidelines to ensure proper ordering of needed tests needs to be developed and enforced.
Specific target for improvement
Looking at the data in the two dashboards, it would seem that creating a plan to ensure
compliance with the five recommended sepsis interventions that we are currently tracking is the 4
best course of action with an emphasis on the administration of Vasopressors and blood culture draws as these are the lowest areas noted on the available dashboard metrics and have the greatest room for improvement. This recommendation is coming from both a patient safety improvement and ethical care standpoint. Seventy-five percent of the inpatient mortality in the sample data from the third quarter was seen in patients that did not receive the full suite of interventions that they should have. This is unacceptable. Guidelines need to be put into place for our care teams to follow.
Ethical and Sustainable Recommended Actions
To address this issue a training program should be designed to introduce our nurses and doctors to the new practice guidelines. This program also needs to emphasize the importance of compliance with performing all necessary interventions from a patient safety standpoint. The addition of automated order protocols could help ensure timely responses to needed testing when a diagnosis of Sepsis or suspected sepsis is entered into the system.
The facility should involve key stakeholders including the ordering providers, nurses, laboratory personal and the I.T. department. Each department is needed to ensure the timely ordering and completion of the core bundle testing for Sepsis. As noted by Medicaid.Gov (n.d.) the state of MN has a 57% rate for obtaining the needed tests within the specified time frame and Eagle Creek is currently reporting 84%, but there is still room for improvement to help ensure the quality care and outcomes of the patients served.
Admittedly, this approach does not address our nurse staffing shortage. However, by formalizing training and educating the staff that we do have along with having automated ordering prompts, hopefully we can mitigate some of the staffing challenges while a solution for them is worked out with human resources and finance.
Thank you for your time. I hope this report has addressed all of the questions you had in mind when you sent me this data. If there needs to be further work regarding this issue, please come see me. I would be interested in helping to shape the direction that the organization will
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take in developing the policy and practice guidelines for ensuring proper care of patients who

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