NURS FPX 6004 Assessment 1 Dashboard Metrics Evaluation-Capella University

NURS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Dashboard Metrics Evaluation

Dashboard Metrics Evaluation In this century of healthcare legislation, enhancing the effectiveness of healthcare facilities in terms of quality and safety standards has become more crucial (Slakey et al., 2021). Most healthcare facilities have developed quality and safety improvement plans to enhance treatment for communities continuously, and these plans require performance indicators or monitoring dashboards (CDC, 2019). The performance monitoring dashboards provide platforms for transmitting information related to quality and safety that provide stakeholders with a clear picture of the plan and indicate accomplished goals by providing the performance of the care facility (Khan et al., 2019). The dashboards provide day-to-day information on improvements and underperformance to determine the usefulness of quality delivery. This assessment evaluates the diabetes dashboard of Mercy Medical Center (MMC) at Vella Health’s organization hospital.

Evaluation of Dashboard Metrics

The diabetes dashboard presents data collected from diabetic patients who underwent eye and foot examinations and Hgb1Ac tests during 2019 and 2020. The information was classified according to age, gender, and race. For instance, there were 355 White American patients examined, 17 African American patients, 73 American Indian patients, 34 Asian patients, and 73 patients who did not respond. Regarding age, 118 patients had an average age of 20 years, 51 were aged between 21 to 39 years, 214 were aged between 40 to 64 years, and 218 were of average age of 65 years.

NURS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Gender-wise, 214 males and 347 females underwent tests, while two patients did not provide their responses. Eye tests conducted in 2019 were only 200, accounting for 35.5%, and in 2020, 232 tests were performed, accounting for 41%. Foot exams were conducted in 2019 230, accounting for 41%, while in 2020, 235-foot exams were conducted, accounting for 41.7%. Hgb1Ac tests conducted in 2019 were 210, accounting for 37%, while in 2020, 272 tests were conducted, accounting for 48%.

Comparison with National Benchmarks

The current national benchmark percentages for diabetic HbA1c tests, foot exams, and eye tests in the US are as follows:

  • Diabetic HbA1c test: The recommended HbA1c target for most adults with diabetes is less than 7%. However, the American Diabetes Association (ADA) recognizes that individualized targets may be appropriate for some patients, such as older adults or those with a history of severe hypoglycemia. According to the 2021 ADA Standards of Medical Care in Diabetes, the benchmark percentage for patients achieving an HbA1c of less than 7% is 70% (Shin et al., 2021).
  • Foot exam: The benchmark percentage for patients with diabetes receiving an annual foot exam is also 70%, according to the 2021 ADA Standards of Medical Care in Diabetes (Shin et al., 2021).
  • Eye tests: The benchmark percentage for patients with diabetes receiving an annual eye exam is 60%, according to the Healthcare Effectiveness Data and Information Set (HEDIS) 2021 Comprehensive Diabetes Care measure (Bond et al., 2019).

Diabetes is a significant health concern in the United States, affecting millions of people (Wang et al., 2021). A crucial parameter utilized in the management of diabetes is HgbA1c. This metric determines the average level of glucose in the blood over the preceding three months. Foot exams are also crucial for individuals with diabetes since they are at a higher risk for foot problems, including nerve damage and poor circulation. Early detection of these issues through regular foot exams can prevent serious complications such as infections and amputations. Healthcare providers recommend regular HgbA1c testing and foot exams for people with diabetes to help manage their condition and prevent long-term complications (Fulton et al., 2021)

There have been a couple of recent benchmarks related to HgbA1c testing and foot exams in the U.S. Firstly, the American Diabetes Association recommends an HgbA1c target of below 7% for most adults with diabetes, which was updated in 2018. Secondly, the Centers for Medicare and Medicaid Services introduced new payment rules in 2020 that incentivize healthcare providers to perform regular foot exams for people with diabetes to reduce the risk of amputations. These benchmarks are aimed at improving the management and outcomes of diabetes care in the U.S. (Lage & Boye, 2020).

Dashboard Metrics with Laws and Policies

The evaluation of the diabetes dashboard benchmark underperformance is linked to several local, state, and federal laws or policies. For instance, the Affordable Care Act (ACA) requires that all Americans have health insurance, which has increased access to diabetes screening and management services. Additionally, the ACA incentivizes healthcare providers to improve quality by tying payment to performance metrics. This includes regular HgbA1c testing and foot exams for people with diabetes, which can impact the performance of healthcare organizations in meeting the benchmarks (McGinty et al., 2020).

NURS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

State laws such as Medicaid expansion and coverage requirements for diabetes self-management education have also improved access to diabetes care. The National Diabetes Prevention Program (NDPP), established by the Centers for Disease Control and Prevention (CDC), is a federal program aimed at reducing the risk of developing type 2 diabetes. The program emphasizes lifestyle changes, including diet and exercise, which can positively impact HgbA1c levels and prevent long-term complications (BURD et al., 2020).

However, despite these laws and policies, healthcare organizations still face challenges in meeting the benchmarks for diabetes care. These challenges include insufficient resources, lack of patient engagement and education, and limited access to care in certain populations, such as those with low socioeconomic status or living in rural areas. These challenges can lead to unsubstantial conclusions about the effectiveness of the benchmarks in improving the overall quality and performance of healthcare organizations (Andrikopoulos et al., 2021).

Information Gaps

While the Mercy Medical Clinic’s diabetes dashboard provides a wealth of information, there are some areas where their performance falls short of benchmarks set forth by local and state healthcare laws and policies. For example, there is no information about the types of diabetes or the severity of the patient’s condition. It is also unclear how the patients were selected for the tests and exams or whether they were representative of the general population. Additionally, there is no information about the healthcare providers who conducted the tests and exams or their qualifications and experience. Furthermore, there is no information about the specific methods used for the tests and exams, such as the equipment used for eye exams or the criteria for diagnosing foot problems. These information gaps could be addressed by providing more details about the study design, patient selection, and testing procedures (Albright & Fleischer, 2021).

Consequences of Not Meeting the Benchmarks

Failing to meet the prescribed benchmarks for HbA1c testing and foot exams can have significant consequences for healthcare organizations or teams. Firstly, it can lead to poor health outcomes for patients with diabetes, such as an increased risk of complications, hospitalization, and mortality. This can negatively impact the reputation of healthcare organizations or teams, as patients and their families may blame them for their poor health outcomes (Casadei et al., 2021).

NURS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Moreover, failing to meet the prescribed benchmarks can result in financial penalties for healthcare organizations or teams. For instance, if a healthcare provider participates in the Medicare and Medicaid programs, they may be subject to payment reductions if they do not meet the quality measures related to HbA1c testing and foot exams. This can lead to reduced revenue for the organization or team, and can also impact staff morale and job satisfaction (Fermawi et al., 2023).

In addition, failing to meet the benchmarks can also result in legal and regulatory consequences. For example, if a healthcare organization or team is found to violate regulatory requirements related to diabetes care, they may be subject to fines, legal actions, and negative media attention. This can harm the reputation of the organization or team and lead to a loss of trust among patients and stakeholders (Al Assaf et al., 2022).

Implication of Consequences

The consequences of not meeting the prescribed benchmarks for HbA1c tests and foot exams can have significant implications for healthcare organizations or teams. For instance, failing to meet the benchmarks could lead to poor patient outcomes, decreased patient satisfaction, and loss of revenue due to penalties and reduced reimbursements from insurers. Additionally, not meeting the benchmarks could also damage the reputation of the organization or team and reduce its competitiveness in the market (Al Assaf et al., 2022).


One major assumption that can challenge the team is that the data collected from patients who went for an examination of the eye, foot, and Hgb1Ac may not be representative of the entire population of diabetic patients. Moreover, the data only includes information on eye, foot, and Hgb1Ac tests. Therefore, the results may not accurately reflect the overall diabetes management practices of the patients, including medication adherence, lifestyle changes, and other medical tests (Khan et al., 2019).

Evaluation of Benchmark Underperformance

One benchmark that has the potential to greatly improve overall quality or performance in a healthcare organization or inter-professional team is the percentage of diabetic patients who have their hemoglobin A1c (HbA1c) levels tested regularly. HbA1c is a measure of a patient’s average blood glucose levels over the past three months and is considered the gold standard for assessing glycemic control in diabetic patients (Buja et al., 2019).

Impact of Benchmark

Regular HbA1c testing is crucial for effective diabetes management, as it enables healthcare providers to adjust medication dosages and lifestyle interventions as needed to keep blood glucose levels within target ranges. However, underperformance in this benchmark can have significant negative consequences for patient health outcomes, as uncontrolled diabetes can lead to serious complications such as cardiovascular disease, neuropathy, and blindness (Price & St John, 2019).

Therefore, healthcare organizations and inter-professional teams need to prioritize regular HbA1c testing for diabetic patients. Strategies for achieving this benchmark may include implementing electronic medical record reminders for providers, offering education and incentives to patients for maintaining regular follow-up appointments and tests and engaging in collaborative care with multidisciplinary teams that include pharmacists, dietitians, and diabetes educators. Overall, improving performance on this benchmark has the potential to greatly improve the quality of care for diabetic patients, leading to better health outcomes, improved patient satisfaction, and reduced healthcare costs associated with diabetes-related complications (Chatzianagnostou et al., 2019).

Substantiated Benchmark and Related Barriers

One benchmark that could be compared to the percentage of diabetic patients who have their HbA1c levels tested regularly is the percentage of diabetic patients who achieve target HbA1c levels. The American Diabetes Association recommends a target HbA1c level of less than 7% for most adults with diabetes. Achieving this benchmark is important because it has been shown to reduce the risk of diabetes-related complications and mortality (Fang et al., 2022).

This can pose challenges for healthcare organizations and interprofessional teams. Here are some potential reasons why:

  • Patient Factors: Achieving a target HbA1c level of less than 7% may be difficult for some patients due to factors such as age, comorbidities, medication side effects, and lifestyle habits. This can lead to frustration and disengagement among patients who are unable to meet the target and may result in decreased adherence to treatment regimens (Setji et al., 2019).
  • Provider Factors: Healthcare providers may face challenges in helping patients achieve a target HbA1c level of less than 7%, such as lack of time, inadequate training, or limited access to resources. This can lead to the underutilization of evidence-based interventions or over-reliance on pharmacological treatments, which may not be appropriate or effective for all patients (Setji et al., 2019).

Ethical Actions to Address Benchmark Underperformance

Ethical actions that can be adopted by nurses to improve the HbA1c testing underperformance are as follows:

  • Increase patient education: This action is guided by the ethical principle of beneficence, which emphasizes the importance of promoting the well-being of patients. Educating patients on the importance of regular HbA1c testing and the impact of uncontrolled blood sugar levels can improve their health outcomes and prevent further complications (Sørensen et al., 2020).
  • Improve access to testing: This action is guided by the ethical principle of justice, which emphasizes the importance of fairness and equitable treatment for all patients. Increasing access to HbA1c testing for all patients, regardless of their ability to pay, ensures that everyone has the same opportunity to receive the necessary care (Gibson, 2022).
  • Standardize testing procedures: This action is guided by the ethical principle of non-maleficence, which emphasizes the importance of avoiding harm to patients. Standardizing HbA1c testing procedures ensures that patients receive accurate and reliable results, reducing the risk of misdiagnosis and unnecessary treatments (Gibson, 2022).
  • Implement quality control measures: This action is also guided by the ethical principle of non-maleficence, as it aims to prevent harm to patients by ensuring the accuracy and reliability of HbA1c testing. Quality control measures help identify and correct errors in testing procedures, reducing the risk of false positives or false negatives that can lead to incorrect treatment decisions (Zhou & Tan, 2020).
  • Encourage team collaboration: This action is guided by the ethical principle of autonomy, which emphasizes the importance of respecting patients’ rights to make their own decisions about their care. Collaborating with other healthcare providers ensures that patients receive comprehensive care that takes into account their individual needs and preferences. This approach empowers patients to make informed decisions about their health and wellness (Zhou & Tan, 2020).


To conduct benchmark evaluations, it is crucial to identify relevant industry benchmarks and standards, which can be obtained from national or regional healthcare organizations, professional associations, or regulatory bodies. Based on the evaluation of metrics on a dashboard for diabetic patients, the report focuses on the performance of Mercy Medical Center. According to the report, the healthcare center is meeting or surpassing the standards established by healthcare laws or regulations at the local, state, and federal levels. The report highlights the importance of acknowledging underlying assumptions in benchmark evaluation and the potential for certain benchmarks, such as regular testing of hemoglobin A1c levels, to improve overall quality or performance in healthcare organizations or inter-professional teams.


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