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Organizational Benchmark Evaluation Thesis

Organizational Benchmark Evaluation Thesis

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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.Organizational Benchmark Evaluation Thesis

  • 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. Organizational Benchmark Evaluation Thesis

    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. Organizational Benchmark Evaluation Thesis

    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:

    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.

 

dashboard_benchmark_evaluation_scoring_guide.pdf
cf_exemplar_nhs_fpx6004_assessment_1.pdf

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12/19/2020 Dashboard Benchmark Evaluation Scoring Guide Dashboard Benchmark Evaluation Scoring Guide CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED Evaluate dashboard metrics associated with benchmarks set forth by local, state, or federal health care laws or policies. Does not evaluate dashboard metrics associated with benchmarks set forth by local, state, or federal health care laws or policies. Evaluates dashboard metrics not clearly associated with benchmarks set forth by local, state, or federal health care laws or policies, leading to unsubstantiated conclusions about organizational performance. Evaluates dashboard metrics associated with benchmarks set forth by local, state, or federal health care laws or policies. Provides an objective, accurate evaluation of dashboard metrics associated with benchmarks set forth by local, state, or federal health care laws or policies. Clearly articulates organizational performance shortfalls and any gaps in information affecting the evaluation. Analyze challenges that meeting prescribed benchmarks can pose for a heath care organization or interprofessional team. Does not identify challenges that meeting prescribed benchmarks can pose for a heath care organization or interprofessional team. Identifies challenges that meeting prescribed benchmarks can pose for a heath care organization or interprofessional team. Analyzes challenges that meeting prescribed benchmarks can pose for a heath care organization or interprofessional team. Analyzes challenges that meeting prescribed benchmarks can pose for a heath care organization or interprofessional team. Identifies clear implications of such challenges for the organization or team and acknowledges assumptions underlying the analysis. Evaluate a benchmark underperformance in a heath care organization or interprofessional team that has the potential for greatly improving overall quality or performance. Does not evaluate a benchmark underperformance in a heath care organization or interprofessional team that has the potential for greatly improving overall quality or performance. Conducts an evaluation of a benchmark underperformance in a heath care organization or interprofessional team that misinterprets or overlooks factors that are key to a clear understanding the potential for improving overall quality or performance Evaluates a benchmark underperformance in a heath care organization or interprofessional team that has the potential for greatly improving overall quality or performance. Evaluates a benchmark underperformance in a heath care organization or interprofessional team that has the potential for greatly improving overall quality or performance. Provides a compelling and fully substantiated argument for the chosen benchmark’s potential impact on quality of performance. Advocate for ethical action, directed toward an appropriate group of stakeholders, to address a benchmark underperformance. Does not advocate for ethical action to address a benchmark underperformance. Organizational Benchmark Evaluation Thesis
Advocates for ethical action to address a benchmark underperformance. Advocates for ethical action, directed toward an appropriate group of stakeholders, to address a benchmark underperformance. Advocates for ethical action, directed toward an appropriate group of stakeholders, to address a benchmark underperformance. Argues effectively for recommended actions underscored by a clear and perceptive explanation of the ethical principles that 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. https://courserooma.capella.edu/bbcswebdav/institution/NHS-FPX/NHS-FPX6004/200700/Scoring_Guides/a01_scoring_guide.html 1/2 12/19/2020 Dashboard Benchmark Evaluation Scoring Guide CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence. Does not support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence. Sources lack relevance or credibility, or the evidence is not persuasive or explicitly supportive of main points, assertions, arguments, conclusions, or recommendations. Supports main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence. Supports main points, assertions, arguments, conclusions, or recommendations with relevant, credible, and convincing evidence. Skillfully combines virtually error-free source citations with a perceptive and coherent synthesis of the evidence. https://courserooma.capella.edu/bbcswebdav/institution/NHS-FPX/NHS-FPX6004/200700/Scoring_Guides/a01_scoring_guide.html 2/2 \f CAPELLA UNIVERSITY Dashboard Benchmark Evaluation Example Note: The dashboards and data presented in this example assignment are made up. Do not use them in developing your own assessment submission. They’re provided only as examples of how data could be formatted and referred to when you create your assessment. The first section of this example shows two dashboards containing metrics that the evaluation is based upon. If you are using the data from the Dashboard and Health Care Benchmark Evaluation simulation, you are not expected to create new tables to include in your submission. Organizational Benchmark Evaluation Thesis
However, be sure to reference the data from the media simulation in your evaluation. If you choose to use a dashboard or other data from your place of practice, you are expected to provide the data in compliance with HIPAA. The second section is the evaluation of the data presented in the metrics and represents proficient-level work for all of the criteria in the scoring guide. 1 ‘1 CAPELLA UNIVERSITY Sepsis Dashboards from Eagle Creek Hospital Third Quarter Sepsis Intervention Compliance at Eagle Creek Hospital for Adults Presenting with Sepsis Needed Completed Compliance Percentage Initial lactate within 3 hours 27 27 100% Blood cultures drawn prior to antibiotics 27 19 70% Antibiotics administered within 3 hours 27 24 89% Fluid resuscitation if in septic shock within 3 hours 17 15 88% Vasopressors if hypotension persists after fluid resuscitation or lactate > 4mmoL/L within 6 hours 10 6 60% Overall 108 91 84% Intervention Third Quarter Sepsis Intervention Compliance and Inpatient Mortality (Sample) Patient ID # of Interventions Needed # of Interventions Completed Inpatient Mortality 1000 3 2 0 1009 4 4 1 1014 5 5 0 1017 5 5 0 1060 3 1 1 1074 5 4 1 1084 4 2 1 1087 5 5 0 1094 3 3 0 1106 4 4 0 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. 2 \f CAPELLA UNIVERSITY 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. In the case of failing to complete blood draws for cultures prior to administering broadspectrum 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). Organizational Benchmark Evaluation Thesis
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 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 3 \f CAPELLA UNIVERSITY 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 pracitce. Specific target for improvement and suggested actions 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 best course of action. This recommendation is coming from both a patient safety improvement and ethical care standpoint. Organizational Benchmark Evaluation Thesis
Seventy-five percent of the inpatient mortality in the sample data 4 \f CAPELLA UNIVERSITY 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, and 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. Admittedly, this approach does not address our nurse staffing shortage. However, by formalizing training and educating the staff that we do have, 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 take in developing the policy and practice guidelines for ensuring proper care of patients who are presenting sepsis symptoms. References Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., . . . Moreno, R. (2013). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Medicine, 39(2), 165–228. Gaieski, D. F., Edwards, J. M., Kallan, M. J., & Carr, B. G. (2013). Benchmarking the incidence and mortality of severe sepsis in the United States. Critical Care Medicine, 41(5), 1167– 1174. Society of Critical Care Medicine. (n.d.). Surviving sepsis campaign. Retrieved from http://www.survivingsepsis.org/Pages/default.aspx 5 . Organizational Benchmark Evaluation Thesis