Evaluating Performance Metrics and Policy Compliance in Health Care- A Benchmark Analysis

Evaluating Performance Metrics and Policy Compliance in Health Care- A Benchmark Analysis

Metrics Not Meeting the Benchmark for the Organization

The data from the Eagle Creek Hospital sepsis dashboards reveal several areas of underperformance in prescribed benchmarks. The compliance rate for drawing blood cultures before administering antibiotics is only 70%, which falls short of the national average of 60% set by Medicare.gov (Barbash et al., 2019). This gap is concerning, as failing to confirm the infection and responsible pathogen could lead to ineffective or unnecessary care interventions. Also, the finding that 60% of the patient cohort is not receiving vasopressors to treat septic shock is not satisfactory. Guidelines of the Surviving Sepsis Campaign insist that vasopressor therapy should be actively realized in severe hypotension that threatens to live; vasopressor therapy is the only means of maintaining the perfusion level (Weiss et al., 2020). The information in the sample revealed that only one of the patients in need of vasopressors was given them but failed to make a turnaround. This 40% inpatient mortality rate is significantly higher than the benchmarking study findings of 14.7% to 29.9% reported by Rudd et al. (2020).

Health Care Relevant Policies and Laws

The Sepsis Quality Measure created by the Centers for Medicare & Medicaid Services (CMS) under SEP-1 and the guidelines of the Surviving Sepsis Campaign, which are national standards and policies, are the standards being assessed.

Conclusions

These performance disparities regarding the core sepsis care interventions and outcomes among Eagle Creek Hospital patients suggest that the main problems with quality and patient safety exist. In addition to the patient’s life being in danger, the organization may also be in danger of financial penalties and the erosion of its reputation. Redressing such deficiencies is one of the must-do issues to guarantee that the hospital is providing the evidence-based and high-quality care that is needed in the days of healthcare reform.

Areas for Improvement

The report identified the challenges of staffing levels and lack of standardized protocols as the roots of performance gaps; the full picture of the root causes is not yet clear until additional information is gathered. By analyzing the hospital’s sepsis care pathways, training schemes, quality improvement plans, and benchmarking data from other hospitals, valuable information could be found to guide the development of specific interventions. It is essential to develop a good grasp of factors contributing to the situation to come up with a good plan to improve sepsis outcomes and achieve regulatory requirements.

Consequences of Not Meeting Prescribed Benchmarks

Failing to achieve the recommended sepsis care standards at the Eagle Creek Medical Center has far-reaching implications. It erodes the hospital’s purpose and vision, thus compromising patient safety and the trust of the community in the hospital. The matter is worsened by staffing shortages which play into the organization’s financial stability through fines and/or reduced reimbursements. The absence of uniform procedures additionally brings weaknesses in the hospital’s processes, which prevents the hospital from consistently providing quality care. Furthermore, the community’s trust in and the hospital’s ability to retain talent may be undermined, leading to the continuation of quality and resource problems.

Analysis of Challenges

The two primary challenges facing Eagle Creek Hospital in achieving acceptable performance on the sepsis metrics are understaffing and lack of standardized protocols. The nursing unit assigned to adult sepsis patients was understaffed, with a monthly average of 1.375 nurse workload units per staff nurse, well below the target of two patients per nurse. This prevented the medical team from providing prompt, comprehensive care. Additionally, the hospital lacked agreed-upon, evidence-based policies and practice guidelines to govern the implementation of sepsis treatment recommendations from the Society of Critical Care Medicine (Society of Critical Care Medicine, n.d.). Without coherent organizational regulations and standardized procedures, the sepsis interventions were implemented in a haphazard and unprofessional manner. Addressing these fundamental issues of staffing and standardization will be crucial for the hospital to improve sepsis outcomes and meet the prescribed benchmarks.

Key Assumptions Underlying The Conclusions

The discussions related to the challenges in meeting the sepsis performance benchmarks of Eagle Creek are also based on several evaluation points. Here, it is assumed that the staffing data show sepsis ward chronic understaffing, which is the direct reason for the hospital delivery of prompt, comprehensive care for sepsis patients is impossible. Also, the study looks at the lack of approved protocols and processes for the treatment of sepsis (evidence-based) as a significant restraint to the delivery of high-quality care, equal to the constraints witnessed in other complex, regulated industries, such as air traffic control.

Establishing Benchmark Underevaluation to Improve Sepsis Care

The sepsis dashboards at Eagle Creek Hospital reveal that the compliance rate for drawing blood cultures before administering antibiotics is the metric underperforming its benchmark to the greatest degree. The hospital’s 70% compliance rate falls significantly short of the 80% national benchmark set by the CMS SEP-1 Sepsis Quality Measure.

This widespread issue of delayed or missed blood culture collection is a major setback for the organization. Only 60% of the sepsis patient cohort received this critical first step in confirming the infection and identifying the responsible pathogen. This gap in the care process likely contributes to the high 40% inpatient mortality rate, well above the 14.7% to 29.9% national benchmarks.

Given the high volume of sepsis cases at Eagle Creek Hospital, this underperformance in blood culture collection affects a large number of vulnerable patients. Addressing this foundational sepsis care measure presents the greatest opportunity to improve overall quality and outcomes. Developing standardized protocols, providing staff training, and leveraging technology can drive sustainable improvements, thereby enhancing patient safety and demonstrating the hospital’s ethical commitment to the community.

Advocacy Towards the Attainment of the Standardized Sepsis Care Benchmarks Due to Underperformance

Stakeholder Group

To enhance the care foundation of Eagle Creek Hospital, having a multi-stakeholder team would be beneficial. The team should comprise the hospital’s executive leadership, the medical staff (physicians and nurses), the laboratory personnel, and the information technology team.

Rationale for Action

The multidisciplinary stakeholder group should develop an action plan to enhance Eagle Creek Hospital’s sepsis care performance for several critical reasons. Firstly, the hospital has an ethical duty to provide the most effective, evidence-based care to its patients, but major shortcomings in complying with recommended sepsis interventions are jeopardizing patient safety and increasing mortality rates—a violation of the hospital’s duty to its community. Secondly, the performance of poor sepsis metrics puts the organization at financial risk through potential regulatory penalties and reduced reimbursements, threatening its long-term sustainability. Finally, improving sepsis outcomes aligns with the hospital’s mission and vision of being a trusted, high-quality healthcare provider, demonstrating its commitment to excellence and dedication to the well-being of the community it serves.

Ethical Actions

The stakeholder group should apply a multi-pronged approach to eradicate the sepsis care performance shortfalls at Eagle Creek Hospital. This will involve the development of comprehensive, evidence-based guiding principles for sepsis care based on the principles of beneficence and non-maleficence, the provision of training to staff in both technical and ethical care delivery, utilization of technology to ensure standardized interventions, and the introduction of continuous quality improvement processes that are based on the principles of justice and accountability (Varkey, 2021). By being able to do these planned, ethically-guided activities, the stakeholder group can achieve sustainable improvements in sepsis outcomes and, at the same time, meet the hospital’s duty to the patients and community it serves.

References

Barbash, I. J., Davis, B., & Kahn, J. M. (2019). National performance on the Medicare SEP-1 Sepsis Quality Measure. Critical Care Medicine, 47(8), 1026–1032. https://doi.org/10.1097/ccm.0000000000003613

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., & Belley-Cote, E. (2021). Surviving sepsis campaign: International guidelines for the management of sepsis and septic shock 2021. Critical Care Medicine, 49(11). https://doi.org/10.1097/CCM.0000000000005337

Rudd, K. E., Johnson, S. C., Agesa, K. M., Shackelford, K. A., Tsoi, D., Kievlan, D. R., Colombara, D. V., Ikuta, K. S., Kissoon, N., Finfer, S., Fleischmann-Struzek, C., Machado, F. R., Reinhart, K. K., Rowan, K., Seymour, C. W., Watson, R. S., West, T. E., Marinho, F., Hay, S. I., & Lozano, R. (2020). Global, regional, and National sepsis incidence and mortality, 1990–2017: Analysis for the global burden of disease study. The Lancet, 395(10219), 200–211. https://doi.org/10.1016/s0140-6736(19)32989-7

Society of Critical Care Medicine. (n.d.). Surviving Sepsis Campaign (SSC) | SCCM. Www.sccm.org. https://www.sccm.org/SurvivingSepsisCampaign/Home#:~:text=About%20The%20Surviving%20Sepsis%20Campaign

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

Weiss, S. L., Peters, M. J., Alhazzani, W., Agus, M. S. D., Flori, H. R., Inwald, D. P., Nadel, S., Schlapbach, L. J., Tasker, R. C., Argent, A. C., Brierley, J., Carcillo, J., Carrol, E. D., Carroll, C. L., Cheifetz, I. M., Choong, K., Cies, J. J., Cruz, A. T., De Luca, D., & Deep, A. (2020). Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Medicine, 46(S1), 10–67. https://doi.org/10.1007/s00134-019-05878-6

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To complete this assessment:

Review the performance dashboard metrics in your Assessment 1 Dashboard and Health Care Benchmark Evaluation activity, as well as relevant local, state, and federal laws and policies. Consider the metrics that are falling short of the prescribed benchmarks. Note: The writing you do as part of the simulation could serve as a starting point to build upon for this assessment.

Evaluating Performance Metrics and Policy Compliance in Health Care- A Benchmark Analysis

Write a report for a senior leader that communicates your evaluation of current organizational or interprofessional team performance, concerning prescribed benchmarks set forth by government laws and policies at the local, state, and federal levels. In addition, advocates for ethical and sustainable action to address benchmark underperformance and explain the potential for improving the overall quality of care and performance, as reflected on the performance dashboard.
Make sure your report meets the Report Requirements listed below. Structure it so that it will be easy for a colleague or supervisor to locate the information they need, and be sure to cite the relevant healthcare policies or laws when evaluating metric performance against established benchmarks.
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.

Evaluate dashboard metrics associated with benchmarks set forth by local, state, or federal healthcare laws or policies.
Which metrics are not meeting the benchmark for the organization?
What are the local, state, or federal health care policies or laws that establish these benchmarks?
What conclusions can you draw from your evaluation?
Are there any unknowns, missing information, unanswered questions, or areas of uncertainty where additional information could improve your evaluation?
Analyze the consequence(s) of not meeting prescribed benchmarks and the impact this has on healthcare organizations or teams.