Write a 5-page policy proposal and practice guidelines for improving quality and performance associated with the benchmark metric underperformance you advocated for improving in Assessment.
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.
As a master’s-level health care practitioner, you have a valuable viewpoint and voice to bring to discussions about policy development, both inside and outside your care setting. Developing policy for internal purposes can be a valuable process toward quality and safety improvement, as well as ensuring compliance with various health care regulatory pressures. This assessment offers you an opportunity to take the lead in proposing such changes.
Propose organizational policy and practice guidelines that you believe will lead to an improvement in quality and performance associated with the benchmark underperformance you advocated for improving in Assessment 1. Be precise, professional, and persuasive in demonstrating the merit of your proposed actions.
The policy proposal 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.
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- Explain the need for creating a policy and practice guidelines to address a shortfall in meeting a benchmark metric prescribed by local, state, or federal health care policies or laws.
- What is the current benchmark for the organization and the numeric score for the underperformance?
- How is the benchmark underperformance potentially affecting the provision of quality care or the operations of the organization?
- What are the potential repercussions of not making any changes?
- 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 5 pages in length.
Cite 5 references to relevant research, case studies, or best practices to support your analysis and recommendations.
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
- Competency 1: Analyze relevant health care laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
- Analyze the potential effects of environmental factors on recommended practice guidelines.
- Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
- Recommend ethical, evidence-based practice guidelines to improve targeted benchmark performance prescribed by applicable local, state, or federal health care policies or laws.
- Competency 3: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, to inform health care laws and policies for patients, organizations, and populations.
- Explain the need for creating a policy to address a shortfall in meeting a benchmark metric prescribed by local, state, or federal health care policies or laws.
- Competency 4: Develop strategies to work collaboratively with policymakers, stakeholders, and colleagues to address environmental (governmental and regulatory) forces.
- Explain why particular stakeholders and groups must be involved in further development and implementation of a proposed policy and practice guidelines.
- Competency 5: Produce clear, coherent, and professional written work, in accordance with Capella’s writing standards.
- Organize content so ideas flow logically with smooth transitions.
- Use paraphrasing and summarization to represent ideas from external sources.
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Table of Contents
1.0 The Need for Creating a Policy and Practice Guidelines. 3
1.1 Current Benchmark for the Organization. 3
1.2 Benchmark Underperformance. 4
2.0 Recommended Ethical, Evidence-Based Practice Guidelines. 4
2.1 Guidelines on Preventing Medication Errors. 4
2.2 Guidelines on Improving Patient Safety. 5
2.3 Guidelines for Reducing Readmissions. 6
2.3.1 Collection of Critical data. 6
2.3.2 Identification of Root Causes. 7
2.3.3 Activation of a Multi-disciplinary Team.. 7
2.3.4 Focus on offering Culturally-competent Communication. 7
2.3.5 Fostering of External Partnerships and Community Linkages For Promotion Of Continuity Of Care 8
2.4 Guidelines on Reducing Documentation Errors. 8
3.0 Potential Effects of Environmental Factors. 8
4.0 Stakeholder Involvement and Participation. 9
1.0 The Need for Creating a Policy and Practice Guidelines
The primary purpose of this healthcare policy and clinical practice guidelines and associated procedures is to offer standardization in routine operational activities in the selected healthcare setting (Mercy Medical Center). The creation and enforcement of policy and clinical guidelines is essential in offering clarity when responding to core issues and activities that are considered integral in health and safety, regulatory requirements, ethical standards and legal liabilities. The document covers the key policy areas and clinical practice guidelines that will lead to improvements in quality performance associated with the benchmark underperformance reported at the Mercy Medical Center.
Correa et al. (2020) established that the creation of healthcare policies and practice guidelines can become a meaningful starting point through which a healthcare facility may attain sustained improvements in efficiency and productivity, and hence avoiding some of the core issues revolving around readmissions, patient safety, documentation errors, medical errors and other adverse events. Therefore, the centrality of the proposed policy and practice guidelines is basically to communicate to the employees of Mercy Medical Center the desired outcomes, demystify their responsibilities and roles, and establish a clear foundation for the speedy provision of high quality, safe and cost-effective care and support to patients and the respective communities they serve (Stone & Hoffman, 2017).
1.1 Current Benchmark for the Organization
Based on the findings, the current benchmarks for Mercy Medical Center revealed that the healthcare facility recorded higher rates of readmission, (3% higher than the national rate of 34%); higher rates of patient falls ( rose from 3.56 to 11.5 per 1000); increased cases of medical errors; and the eminent lack of proper electronic tracking technology to assist in the proper and accurate documentation of medication and patient information, a pertinent issue that might be contributing to increased rates of documentation and medication errors.
1.2 Benchmark Underperformance
In the healthcare field, Correa et al. (2020) established that benchmarking is a highly crucial method for continuous improvement through the development and adoption of best practices, policies and procedures. However, the benchmark underperformance at the Mercy Medical Center as revealed in the healthcare dashboards indicated the need for adopting requisite interventions and programs aimed at enhancing quality of care and performance of the healthcare entity. Similarly, Irving (2016) noted that systemic failure by a healthcare organization to achieve acceptable performance is practically reflected by the performance gaps in quality outcomes, patient safety, high rates of readmissions, and growing number of documentation and medical errors. Therefore, not making any changes to address benchmark underperformance might greatly undermine the process of performance improvement, and hence exposing the Mercy Medical Center to some of the severe legal, regulatory and ethical pressures associated with non-compliance with the established standards, regulations and performance measures (American College of Physicians, 2017).
2.0 Recommended Ethical, Evidence-Based Practice Guidelines
2.1 Guidelines on Preventing Medication Errors
As identified by the American College of Physicians (2017), some of the practice guidelines to be followed at Mercy Medical Center on prevention of medical errors include:
- The use of medications in a safe and correct manner, proper prescriptions and follow-up and double-checking of labeling.
- Enforcement of double and triple check.
- Involvement of pharmacists, nurses, physicians and other key stakeholders.
- Placement of concentrations on one screen.
- Installation of keypad backlighting.
- Provision of alerts when a dose or rate is out of the normal range.
- Maintenance of sealed drug sets with appropriate dosing for code circumstances.
- Pre-printing of drug labels for identifying of tubing.
- Training of nurses and pharmacists to double check pump doses.
- The deployment of tubing separators.
2.2 Guidelines on Improving Patient Safety
As identified by Rodziewicz et al. (2021), number of patient safety goals must be pursued by the healthcare organization as well as healthcare practitioners in developing and maintaining a safety practice contexts for patients, providers and other stakeholders. They include:
- Identification of patient safety risks and dangers.
- Correct identification of patients through confirming their identity using at least two ways.
- Enhancing communication such as providing test results to the right individual in a quick and reliable manner.
- Prevention of infection through the use of post-op infection antibodies, central line precautions, hand cleaning and catheter changes.
- Prevention of mistakes in surgery through ensuring the surgery process is performed on the appropriate body part and in the most recommended manner.
- Utilization of device alarms to ensure the fast-track response in cases of falls, surgical injuries, equipment failure, mistaken patient identities, wrong-side surgery and other related issues.
- Securing adequate time with patients under the prescription of chemotherapeutic agents and anticoagulants.
- Prevention of nosocomial infections through hand-washing and other safety measures to avoid cases of hospital-acquired infections.
2.3 Guidelines for Reducing Readmissions
Through the Hospital Readmission Reduction Program (HRRP), the Affordable Care Act established the financial consequences for hospitals faced with increased rates of readmissions. Ideally, the HRRP created a scenario where healthcare facilities with disproportionate rates of readmissions received reduced Medicare payments (Centers for Medicare & Medicaid Services, 2018). Upadhyay et al. (2019) commented that the prevention of avoidable readmissions for all patients, irrespective of their ethnicity or race, class, culture, level of health literacy or language proficiency must be given ultimate consideration by healthcare organizations. Some of the high level recommendations for achieving reduction in readmissions include:
2.3.1 Collection of Critical data
Pugh et al. (2021) pointed out that it is essential to ensure relevant data on who is re-admitted, from what location, for what condition, at what cost and due to what factors is collected. Such kind of critical data might be utilized in creating a better understanding of the distinct individual characteristics, specific risk populations, contexts, determinants, and how they relate to re-admissions.
2.3.2 Identification of Root Causes
Mercy Medical Center must focus on conducting a comprehensive analysis of demographics and risk data in order to identify the root causes and aspects associated with patient readmission. Stone and Hoffman (2017) indicated that such information is instrumental in addressing barriers and supporting the development suitable systems and interventions to prevent or overcome them. In another study, the Centers for Medicare & Medicaid Services (2018) indicated that the stratification of data and analysis of quality measures (e.g. 30-day readmission rates, by ethnicity or race, language, social determinants) can prove instrumental in enabling the healthcare organization to measure the equity and quality of care offered.
2.3.3 Activation of a Multi-disciplinary Team
The creation of a multidisciplinary team (comprising of doctors, social workers, quality and safety leaders, professional medical interpreters, allied health professionals) with clear leadership, responsibilities and roles can ensure the mobilization of relevant resources and competencies geared at preventing of reducing cases of readmissions (Upadhyay et al., 2019).
2.3.4 Focus on offering Culturally-competent Communication
Empirical findings by Pugh et al. (2021) revealed that effective and timely clinician-patient communication can trigger positive improvements in medical adherence, patient satisfaction and health outcomes. Therefore, Mercy Medical Center, the provision of effective, culturally-sensitive patient-provider communication may help to boost patient’s understanding regarding their care choices, diagnosis and impact on care, discharge instructions (e.g. symptoms and signs, medicine prescriptions). Some of the notable strategies that can be adopted at the Mercy Medical Center include the writing of discharge instructions, use of interpreters at discharge, team communication, staff training, health literacy programs, and cross-cultural communication (Stone & Hoffman, 2017).
2.3.5 Fostering of External Partnerships and Community Linkages For Promotion Of Continuity Of Care
Mercy Medical Center must focus on creating and maintaining strong partnerships with other care providers as well as community where they service. The Centers for Medicare & Medicaid Services (2018) indicated that partnerships with community service providers may enhance the transition of discharged patients into the community, and guarantee continue of care. The healthcare facility is highly encouraged to introduce community benefit programs and activities as one of the mechanism of tackling social determinants behind the high rates of readmissions through connecting patients to relevant community-based interventions and programs (Pugh et al., 2021).
2.4 Guidelines on Reducing Documentation Errors
Rodziewicz et al. (2021) reported that the used of information and communication technologies (e.g. Electronic Medical Records (EMRs), Computerized Prescriber Order Entry) may help to enhance quality of documentation and reduce avoidable documentation errors and mistakes. At Mercy Medical Center, the adoption of EMRs and Computerized Prescriber Order Entry may not only enhance access to patient medical histories, but also foster the standardization of care with electronic order sets and patient alerts, facilitate computerized ordering and enhance the tracking and reporting of outcomes in real-time. Other practical benefits include enhance comprehensive benchmarking of performance, speedy and accurate sharing of patient information and improvements in communication across the care environments (Julia et al., 2018).
3.0 Potential Effects of Environmental Factors
Mercy Medical Center must foster practice environments that encourages life-long learners and provides necessary incentives for its staff. Some of the regulatory considerations that could affect the recommended guidelines include Health Insurance Portability and Accountability Act (HIPAA), The Health Information Technology for Economic and Clinical Health Act (HITECH) Act, Medicare and Medicaid programs, Children’s Health Insurance Program (CHIP), Affordable Care Act of 2010 and the Patient Safety and Quality Improvement Act (PSQIA) of 2005 (Regis College, 2020). In addition, the identified healthcare facility must also invest in adequate staffing and the mobilization of sufficient financial resources as well as suitable support services to ensure the set guidelines are enforced appropriately (American College of Physicians, 2017).
4.0 Stakeholder Involvement and Participation
All health care providers (pharmacists, nurses, and physicians) at the Mercy Medical Center must be involved in further development and implementation of the proposed policy and practice guidelines. This group of primary stakeholders plays an important role in contributing to the emergence and persistence of error-prone environments, and hence their constant participation can ensure timely identification and reporting of medical and documentation errors, promotion of patient safety and provision of quality care and support to patients following hospitalization (Julia et al., 2018).
Increasing cases of medication or diagnostic errors, documentation errors, readmission rates and patient safety concerns might not only affect the reputation of Mercy Medical Center but also expose it to legal, financial, ethical and administrative challenges that could affect its standing as a compliant and responsible healthcare organization. At the Mercy Medical Center, conducting systems improvement and innovations may become an important step for enhancing the collection of risk and demographics data as well as the identification and tackling of root causes behind the reported benchmark underperformance. In this context, the proposed policy and clinical practice guidelines would aim to enhance compliance with regulations, accreditation requirements and statutes enforced at the local, state and federal levels.
American College of Physicians, (2017). Patient Safety in the Office-Based Practice Setting. https://www.acponline.org/acp_policy/policies/patient_safety_in_the_office_based_practice_setting_2017.pdf
Beauchemin, M., Cohn, E., & Shelton, R. C. (2019). Implementation of Clinical Practice Guidelines in the Health Care Setting: A Concept Analysis. ANS. Advances in nursing science, 42(4), 307–324. https://doi.org/10.1097/ANS.0000000000000263
Centers for Medicare & Medicaid Services, (2018). Guidelines to reducing disparities in readmissions. https://www.cms.gov/about-cms/agency-information/omh/downloads/omh_readmissions_guide.pdf
Correa, V.C., Lugo-Agudelo, L.H., & Aguirre-Acevedo, D.C. (2020). Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: a systematic metareview. Health Res Policy Sys, 18, 74 (2020). https://doi.org/10.1186/s12961-020-00588-8
Irving, A.V. (2016).Policies and Procedures for Healthcare Organizations: A Risk Management Perspective. https://www.psqh.com/analysis/policies-and-procedures-for-healthcare-organizations-a-risk-management-perspective/
Julia, C., Martha, P.K., & Cauchi, R. (2018). Improving the Health Care System: Seven State Strategies. https://www.ncsl.org/Portals/1/Documents/Health/ImprovingHealthSystemsBrief16.pdf
Kripalani, S., Theobald, C. N., Anctil, B., & Vasilevskis, E. E. (2015). Reducing hospital readmission rates: current strategies and future directions. Annual Review Of Medicine, 65, 471–485. https://doi.org/10.1146/annurev-med-022613-090415
Pugh, J., Penney, L.S., & Noël, P.H. (2021). Evidence based processes to prevent readmissions: more is better, a ten-site observational study. BMC Health Serv Res, 21, 189 (2021). https://doi.org/10.1186/s12913-021-06193-x
Regis College, (2020). 8 Important Regulations in United States Health Care. https://online.regiscollege.edu/blog/8-important-regulations-united-states-health-care/
Rodziewicz T.L., Houseman B, & Hipskind J.E.(2021). Medical Error Reduction and Prevention. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/
Stone, J., & Hoffman, G.J. (2017).Medicare Hospital Readmissions: Issues, Policy Options and PPACA. https://www.everycrsreport.com/files/20100921_R40972_fc06768f2d6d1230fa436de550b1bd8db82bd644.pdf
Upadhyay, S., Stephenson, A. L., & Smith, D. G. (2019). Readmission Rates and Their Impact on Hospital Financial Performance: A Study of Washington Hospitals. Inquiry: a journal of medical care organization, provision and financing, 56, 46958019860386. https://doi.org/10.1177/0046958019860386