SOLUTION: NHS-FPX6004 Assessment 1: Dashboard Metrics, Benchmarks, and Policy Decisions

NHS-FPX6004 Assessment 1: Dashboard Metrics, Benchmarks, and Policy Decisions

Dashboard Metrics, Benchmarks, and Policy Decisions

Healthcare organizations develop and implement internal and external policies to meet set performance benchmarks. Dashboard metrics enable healthcare organizations to determine the effectiveness of interventions to implement these policies and make them sustainable in the long term. Infection control policies in organizations help providers to meet national quality standards on patient safety set by agencies like The Joint Commission (TJC), and federal agencies such as the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention (CDC), as well as the Centers for Medicare and Medicaid Services (CMS). This report focuses on an infection control policy in a community health care setting aimed at preventing infections, including healthcare-acquired infections (HAIs).

Infection Prevention and Control Policy

Infection control is essential in healthcare as it determines and influences patient safety, quality care outcomes, and cost-efficiency. At the core of this policy is to improve personal hygiene measures like hand hygiene, use of personal protective equipment and associated measures, reducing hospital-associated infections like CAUTIs, and overall clean environment in the facility. The facility developed this policy because of its significance in reducing the HAI rate. Data from the hospital’s dashboard showed an over 30% rate of infection for inpatients and about 20% for outpatients. The Centers for Disease Control and Prevention (CDC) (2024) posits that infection prevention and control practices are essential for facilities to offer high-quality patient care. Therefore, the policy’s role was to prevent and control infections, and allow the facility to attain better quality status and patient safety. These included reducing infection rates to less than 5% across all settings and patient populations. The dashboard data showed more infections among patients in critical care, like the high dependence unit (HDU), with one patient succumbing while others stayed longer due to HAIs. Based on the Health Insurance Portability and Accountability Act (HIPAA), the report cannot reveal protected health information on these patients.

The policy is critical for the organization to attain compliance with regulatory mandates since infections are preventable events, and CMS does not reimburse facilities for costs associated with their occurrences. The policy is essential as it contributes to the organization’s overall goal of delivering quality and safe care to patients and enhancing satisfaction among all stakeholders. The policy has improved patient care, enhanced staff motivation and performance, and reduced the cost burden associated with infections, leading to resource availability for other purposes (AHRQ, 2023). Current data shows a significant reduction in infections, especially HAIs, from 30% to less than 5% across all areas. The implication is that the policy is effective in preventing and controlling infections in the organization.

Policy Analysis: Compliance and Divergence from Relevant Healthcare Law

The infection control and prevention policy in the facility demonstrates attempts to comply with various guidelines, laws, and even best practices set by professional organizations, agencies, and existing benchmarks. At the core of the policy is having evidence-based practices and interventions to improve infection control and ensure the safety of care. Consequently, the policy aligns with healthcare laws like the Affordable Care Act of 2010, CDC guidelines on infection prevention and control based on best practices, CMS regulations, and The Joint Commission’s requirements. Additionally, the policy aligns with best practices by healthcare providers like Parkland’s Preventive Care model, whose dashboard metrics show lower rates of infections compared to national averages (Parkland Health, 2025). The Affordable Care Act seeks to improve access to quality and affordable care, implying that the law requires healthcare facilities to reduce adverse events like HAIs.

Again, the CDC (2024) guidelines show how organizations can implement certain evidence-based practices like leadership support, education and training of personnel on infection prevention, patient, family, and caregiver education, and monitoring and feedback to improve infection control measures. The Joint Commission outlines practices like meeting CMS regulations, having nationally recognized infection control and prevention guidelines, and using evidence-based interventions to design policies and procedures to promote patient and staff safety (TJC, 2023). The policy complies with the law and existing policy guidelines as well as best practices since it has led to a significant reduction in infections, including HAIs. CMS value-based care requires quality metrics for reimbursement. Imperatively, this policy shows a reduction of infections to about 0.68, which is below the national average of 1 in every 100 patients. These benchmarks set by the guidelines and best practices by Parkland Health demonstrate that facilities can attain best infection standards and practices to reduce occurrences and enhance patient safety and quality care. Further, the Agency for Healthcare Research and Quality (AHRQ) (2023) advances that effective infection control and prevention measures must be founded on best benchmarks in the industry and follow national guidelines.

Consequences of Benchmark Underperformance

Underperformance of a benchmark in infection control and prevention, like lacking hand hygiene and HAIs mitigation measures, means that a facility cannot meet required and mandated quality standards and practice guidelines. Missing the required benchmarks can have devastating effects on the organization and even healthcare teams (Ding, 2024). These effects are legal, ethical, and financial in nature. Firstly, infections are among the leading causes of increased cost of care due to longer stays in hospitals, and negatively affect the quality of care. Secondly, noncompliance with existing legal requirements may have far-reaching effects, like a lack of resources through reimbursement by CMS, financial penalties, and lower ratings by CMS.

Thirdly, infections are unethical based on the ethical principles of beneficence, non-maleficence, and justice (AHRQ, 2023). For instance, infections harm patients and hinder the acquisition of healthcare benefits. Secondly, they lead to more resource allocation due to lengthened stays in hospitals at the expense of other individuals who deserve care and have to wait for it. As Martinez (2024) observes, performance metrics of healthcare organizations are important in improving patient safety, quality of care, and meeting regulatory requirements. Therefore, compliance improves trust, leads to fair resource allocation, and enhances benefits to patients and healthcare providers.

Evaluating Benchmark Underperformance for Quality Improvement

Internal assessment and audit showed two areas of benchmark underperformance based on the CDC’s infection prevention and control practice for safe care delivery, comprising limited leadership support, standard precautions, and performance monitoring and feedback. Effective leadership support is essential as it improves the attainment of quality improvement through resource allocation. CDC (2024) asserts that infection control programs can only succeed if they have visible and tangible support from the facility’s leadership. Secondly, standard precautions are broad measures that the facility does not implement in totality, yet they are basic practices in patient care, irrespective of the patient’s status. The other aspect is infection surveillance as part of risk management initiatives to reduce and control infections. The facility does not implement aspects like hand hygiene measures, and sufficient levels of risk assessment are lacking.

Thirdly, the CDC (2024) guidelines require regular performance monitoring and feedback to show performance metrics on dashboards aimed at improving infection prevention and control. These benchmarks are essential as they help organizations to evaluate areas for improvement, and implement best practices and measures like hand hygiene, environmental cleanness, and overall practices to enhance quality and safe patient care delivery (Garcia et al., 2022). Surveillance enhances root-cause analysis of infections and detection of pathogens. The World Health Organization (WHO) (n.d.) implores facilities to increase infection surveillance for effective responses and reduce possible spread. Attaining these benchmarks leads to positive interactions with providers and patients, and increases trust in the facility to provide the best care for diverse patients, including customized interventions.

Advocacy for Ethical and Sustainable Solutions to Benchmark Underperformance

Dealing with benchmark underperformance ethically and sustainably requires healthcare entities to establish an evidence-based environment that integrates shared accountability and responsibility and patient-centered care. The ethical approach should entail upholding ethical principles like beneficence, autonomy, and non-maleficence as well as justice (Willmington et al., 2022). The sustainability of the infection control and prevention program requires integration of best practices and adherence to benchmarks as illustrated by existing legal requirements, guidelines, and policy implementation in different healthcare settings (Kubde et al., 2022). Consequently, the facility introduced two strategies that included ethical training of all stakeholders and a systematic integration of the best practices. The training reinforced application of ethical values, a shared approach to infection prevention and control, and accountability based on collective responsibility. The implication is that all stakeholders are accountable and should do their part. The inclusion also showed the commitment of all stakeholders to shared decision-making and respect for patient dignity through safe care delivery.

The systematic integration means that continuous quality improvement is part of the organization’s routine practices and activities. The integration means that new staff and current staff get information and training on infection control measures, best practices, and benchmark guidelines to inform their actions and decisions in care delivery (Ding, 2024). These actions are essential for the long-term sustainability of the policy as part of the care delivery culture in the organization. These actions will improve ethical values like beneficence, reduce harm, and ensure equity for patients and care providers.

Conclusion

Effective policies should align with existing benchmark practices, guidelines, and laws to demonstrate good intentions and focus on patient care quality. The current infection prevention and control policy in the facility demonstrates efforts to improve quality care through reducing patient harm emanating from different types of infections. Based on CDC guidelines and other benchmark requirements, the evaluated policy is essential for the facility to attain benefits, including better care delivery and more resources from CMS. Therefore, the organization should implement this policy because of its ethical and sustainability implications.

References

Agency for Healthcare Research and Quality. (AHRQ) (2023). National Healthcare Quality and

Disparities Report. https://www.ahrq.gov/research/findings/nhqrdr/index.html

Centers for Disease Control and Prevention (CDC) (2024, April 12). CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings. https://www.cdc.gov/infection-control/hcp/core-practices/index.html

Ding, X. (2024). Benchmark and performance progression: Examining the roles of market competition and focus. Journal of Operations Management, 70(3): 381-410. https://doi.org/10.1002/joom.1288

Garcia, R., Barnes, S., Boukidjian, R., Goss, L. K., Spencer, M., Septimus, E. J., … & Levesque, M. (2022). Recommendations for change in infection prevention programs and practice. American journal of infection control, 50(12): 1281-1295. https://doi.org/10.1016/j.ajic.2022.04.007

Kubde, D., Badge, A. K., Ugemuge, S., Shahu, S., & Badge, A. (2023). Importance of hospital infection control. Cureus, 15(12): e50931.DOI: 10.7759/cureus.50931

Martinez, W. (2025). From insight to action: tackling underperformance in health professionals. BMJ Quality & Safety, 34(2): 77-80. https://doi.org/10.1136/bmjqs-2024-017682

Parkland Health (n.d.). Hospital-Acquired Infections.

https://www.parklandhealth.org/hospital-acquired-conditions

The Joint Commission (TJC) (2025). Infection Prevention and Control & Antibiotic Stewardship.

https://www.jointcommission.org/en-us/knowledge-library/infection-prevention-and-control-resource-center

Willmington, C., Belardi, P., Murante, A. M., & Vainieri, M. (2022). The contribution of benchmarking to quality improvement in healthcare. A systematic literature review. BMC

health services research, 22(1): 139. DOI: https://doi.org/10.1186/s12913-022-07467-8

World Health Organization (WHO) (n.d.). Infection Prevention and Control. https://ihrbenchmark.who.int/document/15-infection-prevention-and-control

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Introductions

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.

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.
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.
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.
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.
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.

Report Requirements

The report requirements outlined below correspond to the scoring guide criteria, so be sure to address each main point. Read the performance-level descriptions for each criterion to see how your work will be assessed. In addition, be sure to note the requirements for document format and length and for supporting evidence.

Describe how the selected policy complies with or diverges from the requirements outlined in the healthcare law.
Identify benchmarks associated with a healthcare law, policy, or guideline.
- For additional information on benchmarks, you may go to the AHRQ website and explore their Data Tools. Use the AHA and NHQDR Navigation Instructions [PDF] for step-by-step instructions.
Evaluate dashboard metrics associated with benchmarks set forth by local, state, or federal healthcare laws or policies.
- Identify a benchmark underperformance.
Analyze the consequences of not meeting prescribed benchmarks and the impact this has on healthcare organizations or teams.
- 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.
Advocate for ethical and sustainable actions, directed toward an appropriate group of stakeholders, needed to address a benchmark underperformance.
Organize content so ideas flow logically with smooth transitions.
- Proofread your report, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your evaluation and analysis.
Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.
- Be sure to apply correct APA formatting to source citations and references.

Report Format and Length

Format your report using current APA style.

Use the APA Style Paper Tutorial [DOCX] to help you in writing and formatting your report. Be sure to:
- Remember to utilize the authoring organization as the group author if specific authors are not noted.
- If there is no date (n.d.), provide the date retrieved and from.
- Include more information than the URL.
- Include a title and reference page. Do not use an abstract.
Your report should be 3–5 pages in length, not including the title page and references page.

Supporting Evidence

Cite 4–6 credible, current, and scholarly references. Include the policy, law, or guidelines.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 1: Analyze relevant healthcare laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
- Describe how a selected policy complies with or diverges from the requirements outlined in a related healthcare law.
- Analyze the consequences of not meeting prescribed benchmarks and the impact this has on healthcare organizations or teams.
Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
- Advocate for ethical and sustainable actions, directed toward an appropriate group of stakeholders, needed to address a benchmark underperformance.
Competency 3: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, to inform healthcare laws and policies for patients, organizations, and populations.
- Identify benchmarks associated with a healthcare law, policy, or guideline.
- Evaluate a benchmark underperformance in a healthcare organization or interprofessional team that has the potential for greatly improving overall quality or performance.
Competency 5: Produce clear, coherent, and professional written work, in accordance with Capella’s writing standards.
- Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.