NURS-FPX 6004 Assessment 2: Policy Proposal

Policy Proposal

            The healthcare procedures and policies are important because they ensure that all healthcare organization adheres to the set guidelines that define professionalism in healthcare. They also make an organization compliant with the set accreditation requirements and regulatory statutes. The review of the policies should be done regularly to update the policies that would ensure that an organization meets the local, state, and national levels (Zhang et al., 2022). The purpose of this assignment is to propose policies and practice guidelines for improving quality and performance associated with the benchmark metric underperformances observed after analysis of the diabetes dashboard at Mercy Medical Center. This paper will also outline the performance scores, their effect on quality, repercussions, ethics, and evidence-based strategies that can handle the performance issue.

Current Benchmark for the Organization and the Numeric Score for the Underperformance

nurs-fpx 6004 assessment 2: policy proposal

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            The dashboard data has shown two main areas that need to be examined to meet the current expectation of the patients. The declining HgbA1c exams and the low foot exam rate are some of the biggest concerns in this hospital (Vujosevic et al., 2020). The local and federal benchmark metric for diabetic foot and HgbA1c screening is 76.17% (Cooksey, 2020). However, the dashboard data on both HgbA1c and exams rates are 62% and 64% respectively in the last quarter of 2020. This value is lower than the national benchmark and indicates that the clinic needs to improve on this part. The increase in these exams shows that many patients are cautious about their diabetic status and can undertake important screening tests that can help identify potential related complications. This information shows that many patients fail to undertake these exams, which gives Mercy Medical Center a hard time to identify the difficulties early enough and devising the most effective remedy.

How Underperformance Affects the Quality of Care

            One metric that shows that a clinic is improving the quality-of-service delivery is patient education. This measure heightens the understanding of patients concerning various health issues that need to be in place to improve service delivery (Cooksey, 2020). Hospitals should ensure that HgbA1c exams and the low foot exam rate are high by intensifying patient education and health promotion awareness. This criterion would help identify diabetic complications early and devise the most effective measures to mitigate the complications. Low HgbA1c exams and low foot exam rates are linked to poor-performing hospitals and result in ineffective management of diabetic complications (Vujosevic et al., 2020). The complication risks need to be avoided as it raises the cost of treatment and may increase patient mortality rates. Cooksey (2020) confirms that diabetic complications are negative healthcare outcomes that affect patients’ safety. Therefore, for Mercy Medical Center to manage patient safety at the clinic, it should ensure that HgbA1c exams and the low foot exam rates are high to identify diabetic complications early for better healthcare attention.

Repercussions of Not Making Changes

            Failing to address the raised concern would have a negative impact on Mercy Medical Center (Cooksey, 2020). The number of complexities of diabetic patients would increase, reducing the overall quality of health care services at Mercy Medical Center (Cooksey, 2020). For example, the increase in diabetic complications would reduce patient satisfaction as they would feel that the clinic failed to meet the desired patient outcome. The reputation of Mercy Medical Center would also reduce, resulting in a poor financial performance at the clinic. Also, failure to attend to the low HgbA1c exams and the low foot exam rates would imply that the clinic will have more diabetic complications. The increase in these complications affects the work of healthcare workers by increasing the nurse workload (Selvarajah et al., 2019). This effect would spread to other services, reducing the quality of healthcare delivery at Mercy Medical Center.  

Evidence-Based Strategies to Improve Performances

            Increasing HgbA1c exams and foot exam rates would positively affect diabetic patients at the clinic. Various implemented evidence-based strategies expound that hospitals need to improve their effectiveness by improving patient education and clinical accountability. Increasing patient education would enable patients to undergo diabetic screening that would aid in solving diabetic complications (Duffy et al., 2020). Most patients have severe diabetes because they failed to diagnose the disease early. However, these issues could be reduced if patients understand their health status and undertake HgbA1c exams and low foot tests. Other strategies that address low HgbA1c exams and foot exam rates include assigning nurses to oversee the medication plans and scheduling follow-up test on patients after receiving the test results. One can also conduct health promotion campaigns to educate the general population on diabetes.

How the EBP Strategies Enhance Compliances

            Meeting the set benchmarks requires measures that have been proven to be sufficient and effective (Duffy et al., 2020). The proposed evidence strategy above is expected to help Mercy Medical Center meet the local, state, and national benchmarks. For example, by designing an effective promotion plan, patients and the general population will be educated on diabetes (Duffy et al., 2020). Scheduling patients for diabetic screening will also enable them to undertake self-management measures to recover or reduce the severity of diabetes. In terms of communication, the clinic should also devise a better communication channel that updates patients on their screening dates. Besides, the outcome of the tests needs to be instant to advise the patient accordingly. These measures would heighten the quality-of-service delivery and ensure that the clinic meets its health goals (Selvarajah et al., 2019).

Adopting the Strategies at Mercy Medical Center

            At Mercy Medical Center, the diabetic-related screening will be handled through a policy called Diabetic Care. This policy will be a collaborative approach that rallies the healthcare workers to work with the patients, social workers, and physicians to educate patients. The policy will set its guidelines to ensure a process of registering patients for the screening tests. The team will also establish a standard screening process and how complex cases will be undertaken (Duffy et al., 2020). Mercy Medical Center will also adopt health promotions in the community to call patients for screening. Again, ensuring that new strategies are ethical and culturally inclusive will be sent to all healthcare employees for enhanced understanding. Involving all employees in the proposed changes reduces employee resistance and ensures that all employees are focused on meeting the desired patient outcome at the facility.

Environmental Factors and Organizational Resources

            The projected need to increase HgbA1c and foot exams would have a financial impact the clinic needs to meet (Winter et al., 2020). The expansion or increase in the number of patients undertaking diabetic tests would require sufficient resources to execute each test accurately and effectively. A lack of resources will affect the quality of diabetic screening (Winter et al., 2020). Therefore, Mercy Medical Center would have to be ready financially to counter the rising number of patients who are under diabetic screening. Other sources such as more healthcare workers will be required to implement the change. The management at Mercy Medical Center can hire additional nurses on contract to meet the required human resource. Besides, it can access funds from available financial institutions to reduce the financial change.

Regulatory Considerations

            Implementing the new policies would need a healthcare license and a certificate from the state’s office of Health Care Quality (Zhang et al., 2022). The body used the state and federal regulations to set guidelines that all institutions need to meet for any new change at the facility (Winter et al., 2020). The certificate would be important to align with the state and federal laws.

Stakeholders in Implementation

            Effective implementation will involve every healthcare worker at Mercy Medical Center. The team tasked with the implementation of the policies will communicate the changes effectively to ensure that they meet the intended purpose. All employees need to understand the importance of the change and how it would aid in solving diabetic complications at the facility. All stakeholders will be engaged through timely communication and incorporate their thoughts on the proposed changes. This process will eliminate implementation barriers that will ensure a successful change process.


            The diabetic dashboard data on HgbA1c exams and foot exams failed to meet the local, state, and national benchmarks. Therefore, to help change these poor rates, new policies at the clinic would be important in increasing the mentioned rates. Heightening patient education and increasing resources for diabetic screening can be considered to increase the declining HgbA1c and foot exams.


Cooksey, C. (2020). Strategies to Improve Annual Diabetic Foot Screening Compliance at a Family Clinic. Clinical Diabetes38(4), 386-389.

Duffy, J. R., Culp, S., Marchessault, P., & Olmsted, K. (2020). Longitudinal comparison of hospital nurses’ values, knowledge, and implementation of evidence-based practice. The Journal of Continuing Education in Nursing51(5), 209-214.

Selvarajah, D., Kar, D., Khunti, K., Davies, M. J., Scott, A. R., Walker, J., & Tesfaye, S. (2019). Diabetic peripheral neuropathy: advances in diagnosis and strategies for screening and early intervention. The lancet Diabetes & Endocrinology7(12), 938-948.

Vujosevic, S., Aldington, S. J., Silva, P., Hernández, C., Scanlon, P., Peto, T., & Simó, R. (2020). Screening for diabetic retinopathy: new perspectives and challenges. The Lancet Diabetes & Endocrinology8(4), 337-347.

Winter, V., Schreyögg, J., & Thiel, A. (2020). Hospital staff shortages: environmental and organizational determinants and implications for patient satisfaction. Health Policy124(4), 380-388.

Zhang, Y., Bullard, K. M., Imperatore, G., Holliday, C. S., & Benoit, S. R. (2022). Proportions and trends of adult hospitalizations with Diabetes, United States, 2000–2018. Diabetes Research and Clinical Practice187, 109862.

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