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Assessment 1

Dashboard Metrics, Benchmarks, and Policy Decisions

Write a 3–5 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.

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Introduction

In this assessment, you will delve into the world of healthcare laws, guidelines, policies, and benchmarks. As a healthcare professional and leader, it is essential to understand the policies governing your organization and how they align with broader healthcare laws and industry benchmarks. Each member of the healthcare team needs to understand what is needed to provide efficient, effective, and evidence-based care. Through this assessment, you will develop critical analysis skills that will enhance your understanding of healthcare governance and quality improvement efforts.

The purpose of this assessment is to analyze a policy related to your professional practice, organization, or community and compare it to relevant healthcare laws, guidelines, and policies. Then, you will examine how policy, guidelines, and laws align with measurable healthcare benchmarks and implications for quality improvement.

Instructions

Use the 

Assessment 1 Template [DOCX]
 to complete this assessment.

1.
Topic Selection: Choose a topic of interest that you would like to work in your organization or one where you have worked before or are interested in working.

· Look at the American Hospital Association, Center for Medicare & Medicaid, the Institute of Health Care Improvement, or the Joint Commission Patient Safety Goals.

· If you cannot locate one, look at local, state, or federal issues.

2.
Policy Application: Find a policy, set of guidelines, or government regulations and apply it to the organization’s work on the chosen topic. You may choose a policy you have access to from your organization. Other sources of policies include those published online from a different healthcare organization.

· Describe clearly how the selected policy complies with or diverges from the requirements outlined in a related healthcare law, providing evidence to support your position.

· Discuss the potential legal, ethical, or financial implications of non-compliance with the policy and its alignment with healthcare law or professional guidelines.

· Consider the consequences for individual practitioners, stakeholders, and the healthcare organization.

·
Examples of Laws, Regulations, and Standards:

· Centers for Medicare & Medicaid Services (CMS) Federal regulations and guidance.

· CMS Hospital Readmissions Reduction Program (HRRP).

· CMS Inpatient Quality Reporting Program (IQR).

· CMS Improving Medicare Post-Acute Transformation Act of 2014 (IMPACT Act) is a federal law that standardizes patient assessment data in post-acute care settings.

· CMS Social Determinants of Health (SDOH) requirements.

· The Joint Commission Standards and Measures.

· Commission on Accreditation of Rehabilitation Facilities (CARF).

· Centers for Disease Control and Prevention (CDC) – National Healthcare Safety Network.

· National Database of Nursing Quality Indicators (NDNQI).

· Agency for Healthcare Research and Quality (AHRQ).

· National Committee for Quality Assurance (NCQA) – Healthcare Effectiveness Data and Information Set (HEDIS) measures.

· The Patient Safety and Quality Improvement Act of 2005 (PSQIA) protects healthcare workers who report unsafe conditions at their practices. The law encourages individuals to report medical errors while maintaining patient confidentiality.

3.
Benchmark Comparison: Identify a benchmark or strategic goal and compare it to the policy, guideline, or regulation and goal that is not at the desired goal or range.

· A benchmark in healthcare is a standard or point of reference used to measure and compare the performance of healthcare organizations, departments, or individual clinicians.

· Benchmarks are used to identify areas for improvement and set goals for quality improvement.

· These benchmarks could include national quality indicators, best practices recommended by professional organizations, or performance metrics set by regulatory agencies.

· If you do not have access to your organization’s benchmarks, one of the resources on the 

Assessment 1: Benchmark Resources
 reading list can be utilized to access benchmarks.

· Describe the benchmarks associated with the healthcare law, policy, or guideline, and clearly articulate the connections between benchmarks and policy. There may be more than one benchmark for a topic, but only one is needed.

· The comparison should include the benchmark’s numerical value.

·

Parkland Health: Preventive Care
 example: This information is an example of available data that could be used to build a case for what needs improvement based on underperformance and help justify the consequences of not meeting the standards set for the CMS Core Measures. Some hospitals share lots of detail, while others provide limited information.

4.
Metric Analysis: Look at the metric or measure that is not being met or in compliance with the policy, guideline, or regulation and analyze what needs to be added, removed, or developed to ensure the benchmark is met.

· Consider how an Interprofessional Education (IPE) team can develop a Quality Improvement (QI) plan to improve these outcomes.

· Analyze the consequences of not meeting prescribed benchmarks and the impact this has on healthcare organizations or teams.

· The 

Agency for Healthcare Research and Quality Indicators
 reading list is a good place to find this type of information.

· Be sure to clearly identify implications and acknowledge assumptions underlying your analysis.

5.
Sustainability and Ethics: Describe what is needed to ensure that the project plan will be sustainable, efficient, effective, and evidence-based.

· Consider how adherence to benchmarks can drive positive outcomes in patient care, safety, and overall organizational performance.

· Explain how you can ensure the solution is ethical and protects vulnerable and diverse patient populations.

· Advocate for ethical and sustainable actions directed toward an appropriate group of stakeholders, arguing effectively for recommended actions with a clear and perceptive explanation of the ethical principles and sustainability goals to guide such actions.

Note: Ensure your data are Health Insurance Portability and Accountability Act (HIPAA) compliant. Do not use any easily identifiable organization or patient information.