NHS FPX 6004 Assessment 1
Phillip September 28, 2023 No Comments

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Student Name

Capella University

NHS-FPX 6004 Health Care Law and Policy

Prof. Name



NHS FPX 6004 Assessment 1

Dashboard Metrics Evaluation 

Healthcare organizations worldwide are constantly striving to improve quality and safety performances to keep pace in the healthcare systems. Most of these organizations are putting efforts to develop quality and safety programs whereby they enhance their performances to optimize with the national, state, and federal benchmarks that have been set for the healthcare sector. One such indicator in healthcare organizations is the performance dashboard. Performance dashboards are the systems that provide information on the current practices and the quality and safety indicators, which is helpful for healthcare organizations to identify if the desired outcomes are achieved and provide meaningful actions to further improve the quality of healthcare and safety for the consumers (Helminski et al., 2022). 

This assessment is focused on the evaluation of the Vila Health Organization’s dashboard metrics as compared to the national, state, or federal benchmarks and then the shortfalls of the organization will be discussed. Further, an analysis will be presented to highlight the consequences of not meeting the desired criteria. Moreover, the underperformance of a specific benchmark will be shared, and how it can be addressed to improve the quality and performance of the organization. Lastly, ethical and sustainable actions will be presented that can be used by stakeholders to address the concerned benchmark underperformance. 

Evaluation of Dashboard Metrics with Benchmarks Set

The dashboard metrics used for this assessment belong to the Mercy Medical Center (MMC) which is one of the best healthcare organizations in the region which is why they need to use the information to identify the best-practice strategies to improve the quality and performance of the healthcare organization. The metrics which are particularly chosen from a diabetes dashboard were eye examination, foot examination, and HBA1c, which have been assessed in four quarters for the years 2019 and 2020. In the last quarter, the majority of the patients are female (62%) and the age group of 40-64 is the highest number of admitted patients (38%).

About 63% of the patient population has been White while only 6% were Asians. The data from the metrics of MMC shows that in 2019, 200 eye tests were conducted which increased to 232 in the year 2020. While for the foot examinations, the number raised from 230 to 235 in both the years respectively. For HBA1c, the number significantly increased from 210 to 272, which is an alarming sign for the Mercy Medical Center. 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

This dashboard data depicts high fluctuations in foot examinations and the HBA1c tests. Whereas a minimal change is observed in the number of eye tests conducted in both years. These examinations are essential for patients with diabetes and the information is imperative for MMC to improve the quality of healthcare services. The benchmark set by National Healthcare Quality and Disparity Report (NHQDR) for foot examination is 84% per year. However, in Mercy Medical Center, approximately 40% of patients had foot exams done in 2019 and almost about 42% in 2020. For HBA1c levels, the Mercy Medical Center data in 2019 showed 37.3% of tests conducted and in 2020 the ratio increased to 48.3% as compared to the national benchmark which states 79.5% of individuals undertaking HBA1c tests at least twice a year.

The benchmark set for eye tests is 75.2% which is different from MMC as it had 35.5% tests in 2019 and around 41% in 2020 (AHRQ, n.d.). The comparison of data between national benchmarks and Mercy Medical Center reveals a higher distance thus, the hospital needs to improve its quality and performance. The missing information that would have improved the analysis and helped the organization to effectively address the problem is the causes of the organization’s shortfall in terms of reduced diabetes examination in the MMC as compared to the national benchmarks. 

Analysis of the Consequences of Not Meeting the Benchmarks 

The major differences between the national benchmarks and the data from MMC have been identified in two pertinent areas; foot examination and HBA1c levels. This underperformance by the organization can lead to several consequences for patients with diabetes. These consequences include; increased hospital readmission rates and morbidities and mortalities for patients. This may also lead to the organization losing its healthcare reputation and the number of patients influx. Due to an inadequate number of tests required for diabetic patients, patients may get improper diagnosis, treatment, and management of their conditions. These may result in poor outcomes and eventually lead to increased readmissions for individuals and high healthcare costs for patients as well as healthcare organizations because according to the Hospital Readmission Reduction Program, the healthcare organization with high readmission rates are penalized for reduced quality and performance (Centers for Medicare & Medicaid Services, 2023). 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Another consequence would be increased morbidity and mortality rate. A thorough examination of the foot and legs as well as HBA1c tests assists healthcare providers in early diagnosis and management of the disease using appropriate interventions. HBA1c is considered a biomarker for the diagnosis of diabetes whereas early and constant foot examination prevents the occurrence of diabetic foot ulcers (Kaiafa et al., 2020; Song & Chamber, 2023). Inadequate tests and examinations may lead to poor quality of care, delayed diagnosis, and treatment, and subsequently cause patients’ death. Lastly, the hospital as well as patients may encounter financial burdens due to high costs associated with the readmission rates and severe morbidities.

These consequences have various implications for the patients, the organization, and the teams. Due to poor quality and undesirable patient outcomes, patients may face concerns of limited healthcare access and reduced trust in the organization, and eventually, the diseases may aggravate. Hospitals and teams may encounter dissatisfaction levels, frustration, and decreased reputation within the healthcare sector. 

Evaluation of the Underperformed Benchmark

The national benchmark for foot examination and HBA1c test is significantly higher than the data from MMC. This indicates that according to the Agency of Healthcare Research and Quality, there is immense importance of these two tests in the prevention, diagnosis, and treatment of diabetes. The HBA1c test acts as an indicator of glycemic control in diabetic as well as non-diabetic patients. It is a reliable measure that not only depicts the state of hyperglycemia but also identifies the associated risks of diabetes and its complications. The results will help the interprofessional team to develop effective measures for the patients’ conditions (CDC, 2022). 

A study on the HBA1c test through point-of-care testing concluded that regular checkups of blood glucose testing especially HBA1c resulted in effective patient outcomes whereby patients shared high satisfaction levels (Smits et al., 2022). This indicates that HBA1c testing has positive outcomes on the appropriate diagnosis and management of diabetes. This will eventually improve the quality of healthcare and organizational performance against national benchmarks. 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Another benchmark that holds importance in diabetes management is foot examination. Diabetic foot is one of the serious complications that is encountered by diabetic patients. NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation. This complication can lead to disability and even death in cases where early signs are not recognized. For this purpose, a foot examination is imperative. Recognition of early signs will reduce the risks of serious complications for the patient thus improving the quality of care (Zhao et al., 2023). Healthcare organizations that meet the national benchmark of foot examinations are more likely to improve patients’ quality of life and their organizational performance. 

Ethical and Sustainable Actions to Address Benchmark Underperformance

To address the underperformance of these benchmarks, MMC must take appropriate actions. These actions should be built on ethical principles and must be sustainable for lasting the changes for a longer period. Ethical actions are important as they will promote the control and management of diabetes for patients by addressing ethical dilemmas, providing patient-centered care, and improving the overall quality of life. The ethical principles that work in healthcare settings are autonomy, beneficence, non-maleficence, and justice. Autonomy is defined as patients’ right to make informed choices and are allowed to use their capacity for their health.

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Beneficence is described as an obligation for healthcare providers to work for the benefit of the patients and their families. Non-maleficence is about not harming the consumers and justice is to make actions and healthcare fair for every individual (Varkey, 2020). Some of the actions that must be taken in terms of diabetes screening to improve quality and performance are: 

  1. Patients must be informed about the importance of getting the tests done. Adequate information should be provided related to the importance, benefits, and disadvantages of not getting screened (Liang et al., 2022). This follows the ethical principle of autonomy and will become a sustainable action as patients will be able to make informed choices at every stage of their lives. 
  2. Effective education and training of nurses are essential to creating awareness among the population for timely and regular screening of the HBA1c levels and foot examinations. NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation. This action falls under the ethical principles of beneficence and justice. Staff education will eventually benefit patients in receiving high-quality care as well as education to improve their life choices related to healthcare (Cheraghi et al., 2023). Moreover, it will be fair for every individual as the same knowledge will be disseminated throughout the group. 


In conclusion, the evaluation of the dashboard data of any healthcare organization against national benchmarks is essential to identify the shortfalls within the organization. This information about underperformance will help in improving the benchmarks using effective, ethical, and sustainable actions. In this assessment, the underperformance of the MMC organization was identified and effective actions were directed at improving the quality of healthcare and enhancing organizational performance. This will eventually improve patient outcomes and organizations can attain reputation and growth in the healthcare sector. 


AHRQ. (n.d.). National Healthcare Quality and Disparities Reports (NHQDR). NHQDR Data Tools | AHRQ Data Tools. Retrieved from. https://datatools.ahrq.gov/nhqdr?count=2&tab=nhqdrnabe&type=subtab 

Centers for Medicare & Medicaid Services. (2023). Hospital Readmissions Reduction Program (HRRP). Retrieved from. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program 

Centers for Disease Control and Prevention. (2022). All about your A1C. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/managing/managing-blood-sugar/a1c.html 

Cheraghi, R., Valizadeh, L., Zamanzadeh, V., Hassankhani, H., & Jafarzadeh, A. (2023). Clarification of ethical principle of the beneficence in nursing care: An integrative review. BMC Nursing22(1). https://doi.org/10.1186/s12912-023-01246-4 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

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 Protocols11(3). https://doi.org/10.2196/34894 

Kaiafa, G., Veneti, S., Polychronopoulos, G., Pilalas, D., Daios, S., Kanellos, I., Didangelos, T., Pagoni, S., & Savopoulos, C. (2020). Is hba1c an ideal biomarker of well-controlled diabetes? Postgraduate Medical Journal97(1148), 380–383. https://doi.org/10.1136/postgradmedj-2020-138756 

Liang, Z., Xu, M., Liu, G., Zhou, Y., & Howard, P. (2022). Patient-centered care and patient autonomy: Doctors’ views in Chinese hospitals. BMC Medical Ethics23(1). https://doi.org/10.1186/s12910-022-00777-w 

Smits, M., Hopstaken, R., Terhaag, L., de Kort, G., & Giesen, P. (2022). Early experiences with quality-assured hba1c and professional glucose point-of-care testing in general practice: A cross-sectional observational study among patients, nurses and doctors. BMC Nursing21(1). https://doi.org/10.1186/s12912-022-00969-0 

Song, K., & Chambers, A. R. (2023). Diabetic foot care. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK553110/ 

Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice30(1), 17–28. https://doi.org/10.1159/000509119 

Zhao, N., Xu, J., Zhou, Q., Hu, J., Luo, W., Li, X., Ye, Y., Han, H., Dai, W., & Chen, Q. (2023). Screening behaviors for diabetic foot risk and their influencing factors among general practitioners: A cross-sectional study in Changsha, China. BMC Primary Care24(1). https://doi.org/10.1186/s12875-023-02027-3