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NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Student Name

Capella University

NHS-FPX 6004 Health Care Law and Policy

Prof. Name


Dashboard Metrics Evaluation 

To improve the quality of healthcare services and performance of an organization, healthcare systems put in constant efforts so that their consumers are satisfied and receive valued healthcare. Most healthcare organizations develop dashboards within their systems to evaluate their performance measures as compared to the national, state, and federal benchmarks. This evaluation assists organizations to review their healthcare practices to improve the quality and safety of the patients and employees. These dashboards provide information on the current outcomes of the practices hence enabling improvements to achieve desired outcomes. 

Similarly, the focus of this assessment is to evaluate the dashboard metrics of Mercy Medical Center (MMC), which is a Vila Health organization, in comparison to the national benchmarks. These dashboard metrics are particularly related to diabetes screening and require extensive efforts to address the shortfalls in improving the management of diabetes and reducing complications for the patients. Along with the identification of the shortfalls and their consequences, this assessment will also present ethical and sustainable actions which can be undertaken to improve the underperformance to enhance the quality of care. 

Evaluation of Dashboard Metrics with National Benchmarks

Mercy Medical Center is one of the greatest healthcare organizations in the state and for this reason, the administration needs to maintain the standards of care within the care center. The hospital has received various achievements in terms of Safe Surgery ratings, Outstanding Patient Experience Award, Top 20 Workplaces awards, and Best Hospital for Patient Experience award. According to the Vila Health resources, the data reveals that in the last quarter of 2020, there were around 214 male patients admitted to the hospital, whereas 347 were female patients.

This accounts for 38% and 62%, respectively. In terms of ethnicity, 3% were African American, 13% American Indian, 6% Asian, and almost 63% were White. Around 38% of patients were from the age group 40-64, while only 9% accounted for 21-39 years old. The dashboard metrics which are presented for this assessment are related to diabetes screening tests – eye tests, foot examinations, and HgBA1c tests. These metrics are evaluated in all four quarters of the year 2019 and 2020. 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

The data is evaluated as compared to the benchmarks set by Agency for Healthcare Research and Quality (AHRQ)’s National Healthcare Quality and Disparity Report (NHQDR). According to this report, adults who are more than 40 years of age and have been diagnosed with diabetes should get their eyes and feet examined per year, whereas for HgBA1c, they must get it checked twice a year. The national benchmarks set for all these screening tests are 75.2%, 84.0%, and 79.5%, correspondingly. The state-level benchmarks set for these tests in the year 2019 are 73.1% for eye tests, for foot exams (82.9%), and for HgBA1c is 70.4% (Agency for Healthcare Research and Quality, n.d.). 

MMC is falling short in all these criteria as only 40-42% of patients have received foot examinations in both years, whereas only 35.5%-41% have gone through eye exams. The rates of HgBA1c tests increased from 37.3% to 48.3% only. This evaluation reveals that MMC should put striving efforts to improve these underperformances to ensure the quality of care is provided and diabetes is effectively managed. Moreover, the missing information about the policy on diabetes screening in the Mercy Medical Center would have improved the analysis. 

Consequences of Not Meeting These Benchmarks 

Diabetes screening tests (eye, foot, and HgBA1c) are imperative for patients who are either pre-diabetic or have been diagnosed with diabetes. If inadequately screened, it may lead to several consequences. The poor consequences include delayed diagnosis which may lead to severe morbidities and may increase mortality rates, financial burden due to deferred management and recurrent hospital readmissions, and poor quality of life. Delayed diagnosis of diabetes and diabetic-related complications (diabetic retinopathy and diabetic neuropathy) may lead to ineffective management of the disease process which may impair patients’ daily functioning and quality of life (Jia et al., 2020). Hospital readmissions are another consequence of inadequate screening which may incur costs for the patients, their families, as well as for the healthcare organization.

This will not only increase the risk of complications but may reduce the quality of life, eventually leading to death (Rubin et al., 2023). The consequences also harm organizational reputation, and financial situation, and may impose harmful impacts on the interprofessional team’s capabilities to perform effective healthcare practices. The assumption underlying the analysis is that every healthcare organization’s mission and goal is to provide quality care to the patients and improve the well-being of the team member too. Therefore, it is significant for any healthcare organization like MMC, to ensure that these benchmarks are attained to prevent patients from these consequences. 

Evaluation of the Underperformed Benchmark

The national and state-level benchmarks identified earlier are significantly different from the dashboard metrics of Mercy Medical Center. However, eye tests and foot examinations have to greatest potential to improve overall quality and performance for patients with diabetes as they are prone to develop diabetic retinopathy and diabetic neuropathy as complications. The American Diabetes Association (ADA) also emphasizes the importance of these tests to early detect the signs of complications and prevent severe outcomes. 

Diabetic retinopathy is described as the mutilation of microvessels of the retina. This may further lead to physical changes in the structure of the retina which may eventually cause blindness. A statistic reveals that around 93 million patients will diabetes are suffering from diabetic retinopathy, worldwide. Moreover, a 2007 report presents that out of 39 million people who are blind 4.8% are blindness due to the same condition (Assem et al., 2020). This data advocates the need for regular eye examinations to prevent the onset of blindness. 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Another important diabetes screening test is foot examination which prevents diabetic neuropathy and reduces the risks of foot ulcers in pre-diagnosed diabetic patients. Diabetic foot ulcers are one of the severe impediments of diabetes which may be because of poor glycemic control. To minimize the risk of diabetic foot ulcers, it is essential to regularly get foot examinations done along with controlling glycemia in the body. Proper screening of feet and care of diabetic feet is essential to prevent the limb from serious outcomes like amputation (Song & Chambers, 2023; Wang et al., 2022). As these studies indicate the importance of eye tests and foot examinations for diabetic patients, it is significantly important for healthcare organizations and Mercy Medical Center to improve their benchmark underperformance so that national standards could be met, quality of care can be improved, and organizational performance is enhanced. 

Ethical and Sustainable Actions to Address the Underperformed Benchmarks

Since evidence-based research has guided the importance of addressing these benchmark shortfalls, it is essential to take actions that are grounded in ethical principles and are sustainable for a long period so that quality and performance can be improved constantly. The ethical principles which are applicable in healthcare settings include – autonomy (informed decisions and respect of patients’ rights), beneficence (to benefit patients and their families), non-maleficence (do not harm patients and their families), and justice (equality and fairness) (Lulé et al., 2019). The actions that can be taken to address these underperformances are: 

  • Patient’s Education: it is imperative to educate patients regarding the importance of foot and eye examinations. This education will include complete information about the benefits of these tests and the risks associated with inadequate screening. Proper information regarding the topic will enable patients to make informed decisions for their healthcare. Healthcare providers must abide by the principle of autonomy whereby, respecting patients’ rights to be informed and make decisions accordingly (Paterick et al., 2020). 
  • Pre-scheduling of appointments: To ensure that patients are adequately screened, healthcare providers should book their eye and foot examination appointments together with their physician follow-ups. These combined appointments have multiple benefits physicians can track the progress and reduce extra responsibilities for the patients too (Lewis et al., 2020). This pre-scheduling of the appointments follows the ethical principles of beneficence and justice whereby patients’ benefit is kept on priority and a fair and equal treatment is undertaken for all the patients. 


To conclude, Mercy Medical Center is short failing for all the metrics of diabetes screening (eyes, foot, and HgBA1c tests) as compared to the national and state-level benchmarks. The organization needs to understand the importance of these metrics and take action to improve underperformance. These actions include patients’ education and the pre-scheduling of appointments. The actions proposed are ethically sound and remain sustainable for constant improvements. Evaluation of dashboard metrics and measures to address these are important for improving the quality of healthcare and organizational performance. 


AHRQ. (n.d.). National Healthcare Quality and Disparities Reports (NHQDR). NHQDR Data Tools | AHRQ Data Tools. Retrieved from. 

Assem, A. S., Tegegne, M. M., Alemu, D. S., Woredekal, A. T., & Tefera, T. K. (2020). Knowledge about diabetic retinopathy, eye check-up practice, and associated factors among adult patients with diabetes mellitus attending at debark hospital, Northwest Ethiopia. BMC Ophthalmology20(1). 

Jia, H., Liu, L., Huo, G., Wang, R., Zhou, Y., & Yang, L. (2020). A qualitative study of the cognitive behavioral intention of patients with diabetes in rural China who have experienced delayed diagnosis and treatment. BMC Public Health20(1). 

Lewis, J. E., Morris, K., Powell, T., Thomas, R. L., & Owens, D. R. (2020). Combining diabetic foot and retinopathy screening: A step in the right direction? – a feasibility study. SAGE Open Medicine8, 205031212094624. 

Lulé, D., Kübler, A., & Ludolph, A. C. (2019). Ethical principles in patient-centered medical care to support quality of life in amyotrophic lateral sclerosis. Frontiers in Neurology10. 

Paterick, Z. R., Paterick, T. E., & Paterick, B. B. (2020). Medical informed choice: Understanding the element of time to meet the standard of care for valid informed consent. Postgraduate Medical Journal96(1141), 708–710. 

Rubin, D. J., Maliakkal, N., Zhao, H., & Miller, E. E. (2023). Hospital readmission risk and risk factors of people with a primary or secondary discharge diagnosis of diabetes. Journal of Clinical Medicine12(4), 1274. 

Song, K., & Chambers, A. R. (2023). Diabetic foot care. In StatPearls. StatPearls Publishing. 

Wang, X., Yuan, C.-X., Xu, B., & Yu, Z. (2022). Diabetic foot ulcers: Classification, risk factors and management. World Journal of Diabetes13(12), 1049–1065.