Dashboard Benchmark Evaluation






Dashboard Benchmark Evaluation


William Newton Hospital, WNH, is categorized as a critical access hospital that aims at serving the Winfield, Cowley population. The hospital, running with 109 employees also provides emergency services with general medical and surgical facilities. According to Buttigieg et al. (2017), the KPI dashboard provides benchmarks that can be used for tracking performance. At the same time, the dashboard also allows for informed decision-making as they are the facilitators that guide target establishment for improvement of service delivery. Strategy development based on the indicators mapping uses the dashboards to tactically apply organizational alignment of goals hence better data processing (Buttigieg et al., 2017). Based on the emergency department volume as provided by the outpatient quality reporting program by the hospital, the ER volume is ranked as low (Hospital Care Data, 2022).

Dashboard Metrics Evaluation

WNH is one of the best healthcare nonprofit rural healthcare facilities in Kansas as reflected that is clear in their indicator’s performance. Under the guidance of national and local policies following the CDC outlines, Kansas Healthcare Plan as drafted and reviewed each financial year is the guidebook to healthcare indicators benchmarks. Hospital Care Data provides a recent look at the WNH dashboard which shows that WNH has a greater than average performance with most of their benchmarks as reported better than the national and Kansas state average.

WNH performs better than national and local averages in all the indicators including preventive care, surgical care, pneumonia care, blood clot care and so much more but they deviate and underperform in the discharge of statin medication which is lower at 42% than both the national 97% and the state 92% averages. However, the concerning metric is the Hospital-acquired infection rate (HAI) which stands at 2.8 against a national average of 1 (Hospital Care Data-b, 2022). This points to a need for improvement of practices and procedures in the hospital to not only avoid liability issues but provide quality care.

It is preferred that HAIs are at zero as they are not only a liability, but they also communicate improper healthcare and indirect harm to patients when present. This is the area of focus for further analysis of the healthcare service delivery improvement for WNH. Coupling the HAIs with hospital and national average mortality indicators, which are higher or in the same range, it can be said that there is a potential risk to reputation and correlation. The federal government mandates the state health agencies to be creators and implementors of HAI programs. Most states including Kansas enforce a payment reduction and adjustment program to compensate for the hospital liability that is incurred (CDC-a, 2022).

The liability of the HAI at the hospital level is weighted by both national and local regulations based on the hospital’s efforts to implement control measures and the level of intentional staff failure leading to patient harm (Shingler-Nace et al., 2019). In WNH the HAIs are associated with Clostridium difficile Infection which has been classified as a mandatory indicator of focus for health safety monitoring (CDC, 2022). At WNH hospital’s average ranking, it is the one ranked at 2.83. Under Medicare, reduction of payment under subsection (d) looks at the total HAC score in the worst performing quartile at a 1% payment rate.

Consequently, the implication of HAI is not only in monetary value only but also in the reputation of the company. No matter how small the number of HAI incidents would be, there is enough clinical significance to matter. As such, it means that the hospital is already facing liability risks on top of the compensation that they are paying because of the Hospital Value-Based Purchasing Program and Hospital Readmissions Reduction Program. Therefore, regulatory and policy concerns are the things that are important in monitoring and implementing HAI reduction strategies (Bergeron, 2017).

Benchmark Challenges

The most impactful challenge for implementation is interprofessional team management. This concern comes with the fact that the reduction of HAIs requires full cooperation between team members’ self-discipline, accountability, and a team that is well trained. This means that every team member will be responsible and accountable when the outcomes are not attained. Given this, it will bring pressure on the team members as there will be inter-supervision that is expected on some level. The result is expected to work on the assumption that the implementation will be a direction given by the manager and supervisors, and the change will take immediate effect upon being announced.

However, assuming that there will be “penalties” and consequences for not attaining benchmark indictor, HAI outcomes will impact the whole team. The tension will be due to the pressure on accountability among each other. While there may be a chance that good will come by increasing communication between the teams, reminding each other can potentially be ground for pointing fingers. As a result, the implication can be a team that will not cooperate and, in many instances, due to pressure of being a potential source of blame. However, this can be dissuaded by the participation of the team in coming up with solutions. This will allow the team to have a cohesive discussion and within that system change in alignment with the team’s needs.

Evaluation of Benchmark Underperformance

An infection acquired during the stay of the patient in the hospital is a liability as well as a moral accountability issue. Clostridium difficile on the stool is transmitted by improper hand washing or protective glove wear, unsterilized equipment, lack of covering mouth eyes, and nose, and irresponsible use of antibiotics. The implication is that at 2.8 value shows there is a clinically significant number for recording that points to the care unit. The implementation of a sanitation program will act on reducing HAI in the hospital. According to the WNH profile, as a 25-bed critical access hospital, the non-profit stature and lack of support from the healthcare system and local taxes means that the facility stretches its funding. As a result, there can be little compensation left to go to the staff leading to fewer retained talents and thus overworked staff. With five rural clinics to be run, it is an overwhelming venture that is also its weakness paint (Data Analyze, 2022). As noted by AHC Media (2018), inadequate staffing can cause laxity in work due to poor management of medication, administration, training, and thus poor delivery of services which are often caused for HAIs.

Advocating for Ethical Action

One of the major causes of laxity in cleanliness that leads to contamination is overworked staff leads. Longer working hours lead to laxity in processes and procedures that follows and within this potential increase in HAIs (Astier et al., 2020). The ethical decision here will be to reduce staff working hours to more a manageable level. Reducing working hours means a change in both process and number of staffing hence a need for finances. Increased training in the staff means a challenge in financing necessary input for improvement. It is not expected that change would be immediately and that means that there will be a need for repetitive training and refocusing skill attainment in the staff. As such, more money would go towards making sure that the staff are retained, and thus a need for improved compensation to retain more talent. With training, there are straightening processes and procedures that ought to be carried out to streamline the improvement and reduction of HAI (Aljamali & Al Najim, 2020). Therefore, there is no physicality and emotionality of the improvement with varied input in the different areas.

As such, it is ethical to act when it comes to hospital-acquired infections by placing processes to curb and avoid contamination instances. However, this interconnects with the need for better compensation and retention of staff are required for talent to be retained and for the state of mind of the workers to be in line with the WNH mission. According to the WNH’s mission of providing skilled healthcare to attain high-quality customer service and reduction of HAI.

The major stakeholders in improving this benchmark are the hospital board of directors who are responsible for strategy development and deployment of finances towards change. The need for finances is the first and highest priority to facilitate the better performance of the HAI benchmark. However, the nurses are the major stakeholder in handling the patients. As such, they play a big role in facilitating improved working culture and attitudes towards better healthcare service provision. This allows for the nurses to handle each patient with care and thus improve their working culture hence service delivery and reduced cost due to litigation or post-control (Hassan et al., 2010).


For the reduction of HAI, the responsibility and accountability go towards the hospital, and it is thus within the patient safety control measures. It is ethical that the stakeholders finance the increase in staff and the practitioner training as a full implementation program. Make sure that the staff does not overwork, follows the human resource regulation, and trains them to handle the patients and procedures better. This makes it easy for actionable reduction of the infections that they could get in the hospital. Therefore, accountable talent retention and an improved working environment are ethical moves that would facilitate benchmark improvement. The aim is to increase sensitization in the staff for better treatment modalities and outcomes tracking. These steps make sure that accountability is taken by the hospital to reduce HAI and also meet the total safety threshold.


Aljamali, N. M., & Al Najim, M. M. (2020). Review in Hospital-Acquired Infection. International Journal of Advances in Engineering Research20(3), 7-20.

AHC Media. (2018). Citing Inadequate Staffing, Nurses Sue Detroit Hospital: No breaks over long work shifts alleged. Hospital Employee Health37(2), 14-N.PAG.

Astier, A., Carlet, J., Hoppe-Tichy, T., Jacklin, A., Jeanes, A., McManus, S., … & Fitzpatrick, R. (2020). What is the role of technology in improving patient safety? A French, German, and UK healthcare professional perspective. Journal of Patient Safety and Risk Management25(6), 219-224.

Bergeron, B. P. (2017). Performance management in healthcare: from key performance indicators to balanced scorecard. Productivity Press.

Buttigieg, S. C., Pace, A., & Rathert, C. (2017). Hospital performance dashboards: a literature review. Journal of health organization and management.

CDC-a. (2022). Kansas Healthcare-Associated Infections State Plan. Retrieved from https://www.cdc.gov/hai/pdfs/stateplans/ks-p.pdf

CDC. (2022). Healthcare- and Community-Associated Infections. Retrieved from https://arpsp.cdc.gov/profile/infections?tab=nhsn

Data Analyze. (2022). William Newton Hospital Profile and History. Retrieved from https://www.datanyze.com/companies/william-newton-hospital/124403760

Hassan, M., Tuckman, H. P., Patrick, R. H., Kountz, D. S., & Kohn, J. L. (2010). Cost of hospital-acquired infection. Hospital topics88(3), 82-89.

Hospital Care Data. (2022). Performance At William Newton Hospital. Retrieved from https://hospitalcaredata.com/facility/william-newton-hospital-winfield-ks-67156/performance

Hospital Care Data-b. (2022). Complications At William Newton Hospital. Retrieved from https://hospitalcaredata.com/facility/william-newton-hospital-winfield-ks-67156/complications

Hospital Care Data-c. (2022). Readmission Rates At William Newton Hospital. Retrieved from https://hospitalcaredata.com/facility/william-newton-hospital-winfield-ks-67156/readmission-rates

Shingler-Nace, A., Birch, M., Hernandez, A., Bradley, K., & Slater-Myer, L. (2019). Minimizing hospital-acquired infections and sustaining change. Nursing202049(10), 64-68

Write a 4-page policy proposal and practice guidelines for improving quality and performance associated with the benchmark metric underperformance you advocated for improving in Assessment 1.


In advocating for institutional policy changes related to local, state, or federal health care laws or policies, health leaders must be able to develop and present clear and well-written policy and practice guideline proposals that will enable a team, a unit, or an organization as a whole to resolve relevant performance issues and bring about improvements in the quality and safety of health care. This assessment offers you an opportunity to take the lead in proposing such changes.


The policy proposal requirements outlined below correspond to the scoring guide criteria, so be sure to address each main point.

· Explain the need for creating policy and practice guidelines to address a shortfall in meeting a benchmark metric prescribed by local, state, or federal health care policies or laws.

0. What is the current benchmark for the organization and the numeric score for the underperformance?

0. How is the benchmark underperformance potentially affecting the provision of quality care or the operations of the organization?

0. What are the potential repercussions of not making any changes?

3. What evidence supports your conclusions?

· Recommend ethical, evidence-based practice guidelines to improve targeted benchmark performance prescribed by applicable local, state, or federal health care policy or law.

. What does the evidence-based literature suggest are potential strategies to improve performance for your targeted benchmark?

. How would these strategies ensure performance improvement or compliance with applicable local, state, or federal health care policy or law?

. How would you propose to apply these strategies in the context of Eagle Creek Hospital or your own practice setting?

. How can you ensure these strategies are ethical and culturally inclusive in their application?

· Analyze the potential effects of environmental factors on your recommended practice guidelines.

. What regulatory considerations could affect your recommended guidelines?

. What resources could affect your recommended guidelines (staffing, financial, and logistical considerations, or support services)?

· Explain why particular stakeholders and groups must be involved in further development and implementation of your proposed policy and practice guidelines.

. Why is it important to engage these stakeholders and groups?

. How can their participation produce a stronger policy and facilitate its implementation?

· Organize content so ideas flow logically with smooth transitions.

. Proofread your proposal, 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 proposal.

· Use paraphrasing and summarization to represent ideas from external sources.

. Be sure to apply correct APA formatting to source citations and references.

Policy Proposal Format and Length

It may be helpful to use a template or format for your proposal that is used in your current organization. The risk management or quality department could be a good resource for finding an appropriate template or format. If you are not currently in practice, or your organization does not have these resources, many appropriate templates are freely available on the Internet.

Your policy should be succinct (about one paragraph). Overall, your proposal should be 4 pages in length.

Cite 3–5 references to relevant research, case studies, or best practices to support your analysis and recommendations.