NHS-FP6004 Assessment 2 Policy Proposal

Draft a written proposal and implementation guidelines for an organizational policy that you believe would help lead to an improvement in quality and performance associated with the benchmark metric for which you advocated action in Assessment 1. Have a look at NHS-FPX6004 Assessment 3 Training Session for Policy Implementation. 

Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.

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 guidelines change proposals that will enable a team, unit, or the 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.

Assessment Instructions for NHS-FP6004 Assessment 2 Policy Proposal

In this assessment, you will build on the dashboard benchmark evaluation work you completed in Assessment 1.

PREPARATION

After reviewing your benchmark evaluation, senior leaders in the organization have asked you to draft a policy change proposal and practice guidelines addressing the benchmark metric for which you advocated action.

In their request, senior leaders have asked for a proposal of not more than 2–4 pages that includes a concise policy description (about one paragraph), practice guidelines, and 3–5 credible references to relevant research, case studies, or best practices that support your analysis and recommendations. You are also expected to be precise, professional, and persuasive in justifying the merit of your proposed actions.

When creating your policy and guidelines it may be helpful to utilize the template that your current care setting or organization uses. Your setting’s 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 care setting does not have these resources, there are numerous appropriate templates freely available on the Internet.

PROPOSAL REQUIREMENTS for NHS-FP6004 Assessment 2 Policy Proposal

Note: The tasks outlined below correspond to grading criteria in the scoring guide.

In your proposal, senior leaders have asked that you:

• Explain why a change in organizational policy or practice guidelines is needed to address a shortfall in meeting a performance benchmark prescribed by applicable local, state, or federal health care laws or policies.
  • What is the current benchmark for the organization? What is the numeric score for the underperformance?
  • How might the benchmark underperformance be affecting the quality of care being provided or the operations of the organization?
  • What are the potential repercussions of not making any changes?
• Recommend ethical, evidence-based strategies to resolve the performance issue.
  • What does the evidence-based literature suggest are potential strategies to improve performance for your targeted benchmark?
  • How would these strategies ensure improved performance or compliance with applicable local, state, or federal health care laws or policies?
  • How would you propose to apply these strategies in the context of your chosen professional practice setting?
  • How would you ensure that the application of these strategies is ethical and culturally inclusive?
  • Does your policy encompass the key components of your recommendations?
• Analyze the potential effects of environmental factors on your recommended strategies.
  • What regulatory considerations could affect your recommended strategies?
  • What organizational resources could affect your recommended strategies (for example, staffing, finances, logistics, and support services)?
  • Are your policy and guidelines realistic in light of existing environmental factors?
• Propose a succinct policy and guidelines to enable a team, unit, or the organization as a whole to implement recommended strategies to resolve the performance issue related to the relevant local, state, or federal health care policy or law.
• Identify colleagues, individual stakeholders, or stakeholder groups who should be involved in further development and implementation of your proposed policy, guidelines, and recommended strategies.
  • Why is it important to engage these colleagues, individual stakeholders, or stakeholder groups?
  • Do your proposed guidelines help colleagues, individual stakeholders, or stakeholder groups understand how to implement your proposed policy?
  • How might engaging these colleagues, individual stakeholders, or stakeholder groups result in a better organizational policy and smoother implementation?
  • Are your proposal and recommended strategies realistic, given the care team, unit, or organization you are considering?
• Communicate your proposed policy, guidelines, and recommended strategies in a professional and persuasive manner.
  • Write clearly and logically, using correct grammar, punctuation, and mechanics.

Integrate relevant sources to support your arguments, correctly formatting source citations and references using current APA style.

• Did you cite an additional 3–5 credible sources to support your analysis and recommendations?

SUGGESTED RESOURCES

The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The NHS-FP6004 – Health Care Policy and Law Library Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you.

Ethical Decision-Making to Improve Quality Performance

This interactive media applies an ethical decision-making process to a workplace health care issue in a hypothetical scenario, which may give you some ideas about how to incorporate ethical considerations into your policy change.

Organizational Ethics Decision-Making Process in Health Care.

This short briefing outlines issues related to quality-related policy development and the potential solutions offered by new regulations such as the Medicare Access and CHIP Reauthorization Act (MACRA) and the ACA.

• • Whitlock, R. (2016, April 15). United States: Talking about the challenge of quality in health care policy development. Mondaq Business Briefing.

NHS-FP6004 Assessment 2 Policy Proposal Example

Statistics show there are preventable measures to reduce falls and avoid them from reoccurring. Typically, 700,000 and 1 million patients fall in hospitals yearly, as stated by the Agency for Healthcare Research and Quality.

Data reports show that many of the patients who fail are not seriously hurt, however, fall rate injuries are substantial. The Joint Commission data shows an average growth in a hospital’s overhead costs for an injury that is fall-related costs the hospital more than $13,000, and the patient’s time spent increases by an average of 6.27 days.

Also, research shows that between 30 and 51 percent of falls result in an injury. (Butcher, 2017) Mercy Medical dashboard metrics data showed an increase in falls and documentation errors due to the mistakes of employees in the years 2015 and 2016.

Many factors can lead to high fall rates, such as poor communication between staff, incorrect documentation, and poor nurse assessments. This policy proposal should be considered to decrease the number of falls and prevent the possibility of falls from occurring. Furthermore, this will increase overall performance, the likelihood of meeting targets, and effective patient care delivery.

Ethical Evidence-Based Strategies

Improving the performance of this benchmark can be accomplished through various ways to decrease preventable falls. Strategic planning will provide a direction in making tough decisions for Medical Mercy Center to deliver superior service to their patients and prevent falls, reducing readmission rates. This policy proposal will support MMC’s leadership to acknowledge a weakness within the organization and implement ways to improve those areas of underperformance.

A lack of communication between staff has caused the fall rates to increase in the center. The “SBAR” concept (situation, background, assessment and, recommendations) is a great tool for maintaining effective communication. Communicating with the staff by using the “SBAR” concept will significantly reduce the chances of miscommunication from the staff and decrease any preventable falls from happening again.

Each time a nurse assesses a patient, using the SBAR concept will support them in identifying the patient’s situation, background, and application recommendations. This will be a great resource in which nurses can then contribute to an enhanced assessment and recommendations on what the patient will need for future treatment. (Lee., Dong,  Lim, Poh., & Lim, 2016).

Strategies should be established for patients who are at risk for falls, which are known to cause injuries to patients. There also should be ways to alert employees if patients are falling more often or patients that could potentially be at risk of falling. Implementing a color-coded system identifying a patient as a fall risk will support decreasing falls and educating new staff about the program.

Proposed Policy

A policy is brought to the attention of the stakeholders and leaders of Mercy Medical due to the systematic failure of reoccurring falls. It is up to the leaders of this organization to bring about change to increase patient satisfaction and patient safety. It is vital to take in the necessary strategies to reduce falls from transpiring. These strategies can contribute to influencing high-quality patient care. (Rawlins, 2014)

Competent staff will support the decrease of stress brought on by an increased workload and the pressures of being short-staffed. Having a knowledgeable team would help when chaotic situations arise and patient care is jeopardized.

It would help relieve the pressures towards a single employee and help to keep each other accountable as a team and decrease unnecessary shortcuts made by an employee. Requiring reporting of fall incidents will help the organization find the areas of weaknesses within the staff and organization. Putting into practice inquiring about the employees’ needs will create a stress-free environment.

Alerts should be issued to patients who are at high risk for falls. Using a color-coded system identifying the fall risk will help employees lessen repeated falls. Educating patients and staff members about the fall prevention policy would be vital in applying safe practices. (Morse,2018)

Conclusion

Human errors are common, but they can be avoided by focusing on education and implementing safe practices. Mercy Medical does not have to be a part of patient fall statistics. Implementing these policies within the organization will provide exemplary safe practices to serve as a role model for organizations and those within the organization.

It’s up to the leaders at Mercy Medical to set the right policies and make impacting changes that would enhance the quality of patient care. We may never be able to prevent patient falls completely, but with strategic efforts and skilled decision-making, we will provide our staff with the best opportunities to minimize falls and maximize patient care.

MMC Fall Prevention Policy

Effective date: October 14, 2019

I. PURPOSE:

To reduce and avoid falls by medication, ensuring proper nurse assessments and reducing risks to provide excellent quality care and correct usage of preventive and protective measures

II. POLICY:

1. All patients should be adequately assessed and classified as to what type of fall risk they are identified when being admitted according to the policy and procedures of Mercy Medical. If any patients are considered high fall risk, all alerts, preventative, and protective measures are considered and must be put in place to ensure proper
2. If a patient has a fall, the fall must be reported and documented in the system and a written report.
3. All staff and leadership must be notified of an unlikely event and must be handled appropriately with the necessary actions for the patient to be taken care
4. The patient must be adequately informed and given instructions and a detailed summary of the

III. Procedure:

1. If an unlikely event occurs, the fall must be reported to the manager and director.
2. An incident report must be filled out on the detailed location, type of fall and description of the
3. A thorough patient follow-up must ensue and all safety precautions should be taken into effect.
4. A follow-up meeting should be held with the manager and all leadership, including staff, to ensure the incident does not occur

NHS-FP6004 Assessment 2 Policy Proposal Resources

Butcher, L. (2017, June 1). The No-Fall Zone. Retrieved from https://www.hhnmag.com/articles/6404-Hospitals-work-to-prevent-patient-falls.

Lee, S. Y., Dong, L., Lim, Y. H., Poh, C. L., & Lim, W. S. (2016). SBAR: towards a common interprofessional team-based communication tool. Medical Education, 50(11), 1167– 1168. https://doi-org.library.capella.edu/10.1111/medu.13171

Morse, J. M. (2008). Preventing patient falls: Second edition. Retrieved from https://ebookcentral-proquest-com.library.capella.edu

Rawlins, M. D. (2014). Engaging with health-care policy. The Lancet, 383, S7-8. doi:http://dx.doi.org.library.capella.edu/10.1016/S0140-6736(14)60048-9

NHS-FP6004 Assessment 2 Policy Proposal Example 2

Policy Proposal

Organizational assessments aim to promote continuous improvement, which requires organizations to develop new healthcare interventions, policies, and practice guidelines or update existing ones. Healthcare practices can become obsolete with time hence the need for continuous improvement. Change improvement events are also informed by data generated in the care delivery processes. Healthcare dashboards are vital data sources that help institutions determine shortfalls in their performance, hence the need for improved interventions. Dashboards present real-time data that allow organizations to measure their performance and evaluate it based on local, state, and national benchmarks used to inform improvement. This essay presents information on underperforming benchmarks from a healthcare dashboard and proposes an evidence-based intervention to manage the underperformance.

Proposed Organizational Policy and Practice Guidelines

The hbA1c test is the underperforming benchmark, with a  hospital turn-up rate of 24% compared to the nationally set benchmark of 79.5% by the Agency for Healthcare Research and Quality (AHRQ, 2021). The low benchmark means that only a few diabetes patients understand the importance and process of diabetes follow-up or only a few take follow-up interventions seriously, especially the HbA1c tests. The other benchmarks are also underperforming, meaning there is a genuine need for improvement in diabetes follow-up interventions. Low HbA1c test turn-up affects patient care provision. It denies the care providers a chance to monitor patient outcomes and the effectiveness of care interventions and represents missed opportunities in detecting care complications.

Failure to address the shortfall will lead to poor patient outcomes, with the development of complications in most patients. Klein and Buse (2020) state that HbA1c tests are reliable and primary predictors of diabetes complications; hence their absence leads to missed opportunities in early complication diagnosis and management. Diabetes causes high healthcare costs, and failure to address the issue will lead to more complications and increased healthcare costs. Andersson et al. (2020) note that diabetes complications impose high costs on organizations and patients, decrease productivity and increase morbidity and mortality. Organizations with poor patient outcomes also develop bad reputations hence the need to address the problem. Diabetes self-management education and support (DSMES) to replace routine diabetes education is the proposed policy and practice guideline change.

Potential Effects of Environmental Factors on Recommended Practice Guidelines

The DSME services at any facility must meet the prescribed standards by the 2022 National Standards for Diabetes Self-Management Education and Support. The recommendations are a set of ten comprehensive standards that DSMES services must meet to be recognized or accredited by the responsible bodies (Davis et al., 2022). The components include a well defines internal structure, stakeholder support, population evaluation, quality coordination overseeing the services, a well-defined DSME team, curriculum, individualization, and ongoing support (Davis et a., 2022).

DSMES should be systematic and organized, and these standards will meet and ensure the DSME system meets the demands. These regulatory requirements can impede the implementation of the intervention due to their complex demands for optimum healthcare services delivery. However, they will also facilitate the intervention to ensure it delivers quality and meets its intended purposes. Various environmental factors could affect the proposed change. The current nurse staffing shortage can negatively affect the institution’s ability to implement the interventions. Winter et al. (2020) note that staff shortage affects the quality of care and leads to poor patient outcomes, including poor patient satisfaction. Nurses are the primary implementers of the proposed changes; thus, their shortage can negatively affect change implementation.

Ethical, Evidence-Based Practice Guidelines to Improve Targeted Benchmarks

DSMES, the proposed policy and guidelines change, is an improved educational intervention that entails patient education in the various areas of diabetes care and integrates education and support, which includes patient follow-up. The intervention targets to improve patient self-efficacy and support them in achieving their desired outcomes (Davis et al., 2022). The components of DSMES include diabetes, types and differences, and preventing and detecting acute and chronic complications. The interventions include exercise, diet, and lifestyle modifications necessary to enhance diabetes control interventions. Other components include diabetes follow-up and increased access to management resources. Ernawati et al. (2019) show that DSME improves patient clinical outcomes such as HbA1c tests, follow-up adherence, and patient quality of life and satisfaction scores, hence its significance

Another strategy is staff education. Staff education increases their vigilance in care delivery and helps them emphasize diabetes patient health monitoring and follow-up (Lawler et al., 2019). Educating staff increases their confidence in care delivery and directly affects their quality of care. Extensive staff education ensures they are competent to work with individuals from diverse cultures and helps them develop care interventions that meet the health needs of all populations. Staff education also helps implement complex strategies such as DSMES and healthcare technologies hence efficiency in care delivery. It also ensures equity through quality and safe care delivery to all patients, hence quality outcomes and patient satisfaction (Lawler et al., 2019).

The last strategy from the literature is patient follow-up programs. Patient follow-up programs are designed to enhance patient healthcare delivery through calls and other reminders such as emails and automated call systems. The patient’s details are fed into the hospital database, and healthcare providers access data and call patients to remind them of their medications, dosages, frequencies, and appointments and monitor their progress (AHRQ, n.d.). In addition, the follow-up programs incorporate ready patients and use communication channels that the patient consents to. The programs consider patient preferences and ensure patients receive the services they need most. Follow-up programs ensure patients feel valued and reduce room for missed follow-up appointments and other care interventions (AHRQ, n.d.).

Importance of Stakeholders and Stakeholder Groups

The nurse manager, charge nurse diabetes unit, nurses, executive leadership, and patient groups will be integral stakeholders in this project. The nurse manager is the nurse responsible for all nursing activities in the facility hence her involvement. Her participation will help improve and advocate for the program as an executive leadership team member by presenting and supporting the idea in executive meetings. The nurses are the implementors of the intervention, and they provide vital perspectives, including their perception of the program vital to its improvement and implementation. Concannon et al. (2019) note that stakeholder involvement will minimize change resistance and promote quality outcomes.

Patients are vital stakeholders in the project as the recipients of care. Their participation in activities like pilot tests will enhance care outcomes assessment and program improvement. The charge nurse in the diabetes outpatient unit will be vital for the leader of the implementation team. She has a vast knowledge of diabetes management and DSME and will thus provide critical information on the design and other interventions hence her inclusion. These stakeholders and stakeholder groups are vital to the success of the proposed intervention. Thus, their participation will lead to a stronger policy and facilitate successful change implementation.

Strategies For Collaborating with Stakeholder Groups

The stakeholder group will play a vital role in implementing the proposal. Their proposal and feedback will help improve the proposal to ensure it meets the holistic needs of patients and does not negatively impact the environment and the healthcare facility. Their collaboration also ensures they present less change resistance to the intervention, promoting their success. It prevents unnecessary delays, and participation will also ensure harmony and unity of direction, which improves decision-making processes and directs efforts toward goal achievement (Santoro et al., 2020). Developing and communicating clear goals, objectives, and directional strategies is the first step in enhancing stakeholder collaboration. The strategy ensures stakeholders understand them fully and thus helps them identify with the change interventions.

Building social relationships through social platforms also enhances collaboration. Holding meetings and social interaction platforms, such as social media groups, can enhance formal and informal interactions, which help build relationships that facilitate collaboration. Lumpkin and Bacq (2019) note that social interactions bring together stakeholders with shared interests and themes and stimulate idea generation, promoting success in developing and implementing innovations. Agreeing and communicating with stakeholders’ clear and straightforward roles and communicating with them helps promote their collaboration. Thizy et a. (2019) note that stakeholders must understand their roles, allowing them to collaborate with other individuals, hence the success of collaborative efforts.

Conclusion

Healthcare improvement depends on extensive consideration of current performance and national and local guidelines. The underperformance in HbA1c tests provoked this quality improvement initiative focusing on policy and practice guideline changes. The focus of the policy proposal is a change from routine diabetes patient care to DSMES, a program that focuses on diabetes patient self-efficacy and access to resources. The current legislation regulating the quality of DSMES programs by the American Diabetes Association will inform the project’s implementation and form the framework for the legal and ethical justification of the program. The stakeholder groups’ involvement will enhance the development and improvement of the policy proposal and influence its implementation.

References

Agency for Healthcare Research and Quality (n.d.). Health Literacy Universal Precautions Toolkit, 2nd Edition: Follow Up With Patients Tool #6. Retrieved 31^st January 2023, from https://www.ahrq.gov/health-literacy/improve/precautions/tool6.html

Andersson, E., Persson, S., Hallén, N., Ericsson, Å., Thielke, D., Lindgren, P., Carlsson, K. S., & Jendle, J. (2020). Costs of diabetes complications: hospital-based care and absence from work for 392,200 people with type 2 diabetes and matched control participants in Sweden. Diabetologia, 63, 2582-2594. https://doi.org/10.1007/s00125-020-05277-3

Concannon, T. W., Grant, S., Welch, V., Petkovic, J., Selby, J., Crowe, S., Synnot, A., Greer-Smith, R., Phil, E. M. D., Tambor, E., & Multi-Stakeholder Engagement (MuSE) Consortium. (2019). Practical guidance for involving stakeholders in health research. Journal of General Internal Medicine, 34, 458-463. https://doi.org/10.1007/s11606-018-4738-6

Davis, J., Fischl, A. H., Beck, J., Browning, L., Carter, A., Condon, J. E., Dennison, M., Francis, T., Hughes, P. J ., Jaime, S., Lau, K. H. K., McArthur, T., McAvoy, K., Magee, M., Newby, O., Ponder, S. W., Quraishi, U., Rawlings, K., Socke, J., Stancil, M., and & Villalobos, S. (2022). 2022 National standards for diabetes self-management education and support. The Science Of Diabetes Self-Management And Care, 48(1), 44-59. https://doi.org/10.1177/26350106211072203

Ernawati, U., Wihastuti, T. A., & Utami, Y. W. (2021). Effectiveness of diabetes self-management education (DSME) in type 2 diabetes mellitus (T2DM) patients: Systematic literature review. Journal Of Public Health Research, 10(2), Jahr-2021. https://doi.org/10.4081/jphr.2021.2240

Klein, K. R., & Buse, J. B. (2020). The trials and tribulations of determining HbA1c targets for diabetes mellitus. Nature reviews Endocrinology, 16(12), 717-730. https://doi.org/10.1038/s41574-020-00425-6

Lawler, J., Trevatt, P., Elliot, C., & Leary, A. (2019). Does the Diabetes Specialist Nursing workforce impact the experiences and outcomes of people with diabetes? A hermeneutic review of the evidence. Human Resources For Health, 17, 1-9. https://doi.org/10.1186/s12960-019-0401-5

Lumpkin, G. T., & Bacq, S. (2019). Civic wealth creation: A new view of stakeholder engagement and societal impact. Academy of Management Perspectives, 33(4), 383-404. https://doi.org/10.5465/amp.2017.0060

Maiorino, M. I., Signoriello, S., Maio, A., Chiodini, P., Bellastella, G., Scappaticcio, L., … & Esposito, K. (2020). Effects of continuous glucose monitoring on metrics of glycemic control in diabetes: a systematic review with meta-analysis of randomized controlled trials. Diabetes Care, 43(5), 1146-1156.

Santoro, G., Bertoldi, B., Giachino, C., & Candelo, E. (2020). Exploring the relationship between entrepreneurial resilience and success: The moderating role of stakeholders’ engagement. Journal of Business Research, 119, 142-150. https://doi.org/10.1016/j.jbusres.2018.11.052

Thizy, D., Emerson, C., Gibbs, J., Hartley, S., Kapiriri, L., Lavery, J., Lunshof, J., Ramsey, J., Shapiro, J., Singh, J. A., Toe, L. P., Coche, I., & Robinson, B. (2019). Guidance on stakeholder engagement practices to inform the development of area-wide vector control methods. PLoS Neglected Tropical Diseases, 13(4), e0007286. https://doi.org/10.1371/journal.pntd.0007286

Winter, V., Schreyögg, J., & Thiel, A. (2020). Hospital staff shortages: Environmental and organizational determinants and implications for patient satisfaction. Health Policy, 124(4), 380-388. https://doi.org/10.1016/j.healthpol.2020.01.001