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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.

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.

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Dashboard Metrics Evaluation Example
Note: The dashboards and data presented in this example assignment are made up. Do not use
them in developing your own report. They’re provided only as examples of how data could be
formatted and referred to when you create your report.
The first section of this example shows two dashboards containing metrics that the evaluation is
based upon. Be sure to reference the data from the Dashboard and Health Care
Benchmark Evaluation simulation in your evaluation.
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.

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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 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%

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.

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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

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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

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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

are presenting sepsis symptoms.

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References

Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., Sevransky, J.

E., Sprung, C. L., Douglas, I. S., Jaeschke, R., Osborn, T. M., Nunnally, M. E.,
Townsend, S. R., Reinhart, K., Kleinpell, R. M., Angus, D. C., Deutschman, C. S.,
Machado, F. R., Rubenfeld, G. D., … Moreno, R., Surviving Sepsis Campaign
Guidelines Committee including the Pediatric Subgroup (2013). Surviving sepsis
campaign: international guidelines for management of severe sepsis and septic shock:
2012. Critical care medicine, 41(2), 580–637.
https://doi.org/10.1097/CCM.0b013e31827e83af

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. https://doi.org/10.1097/CCM.0b013e31827c09f8

Medicare.Gov (n.d.) Hospital Compare. Timely and Effective Care. Sepsis Care.
Minneapolis MN.
https://www.medicare.gov/hospitalcompare/compare.html#cmprTab=2&cmp
rID=240080%2C240053&cmprDist=2.3%2C7.9&dist=25&loc=MINNEAPOLI
S%2C%20MN&lat=44.983334&lng=-93.26667

Society of Critical Care Medicine. (n.d.). Surviving sepsis campaign.

http://www.survivingsepsis.org/Pages/default.aspx

  • Dashboard Metrics Evaluation Example
  • Sepsis Dashboards from Eagle Creek Hospital
    • Third Quarter Sepsis Intervention Compliance
    • Evaluation of dashboard metrics
    • Analysis of challenges in achieving acceptable performance
    • Specific target for improvement
    • References