NHS FPX 6004 Assessment 2 Policy Proposal


NHS FPX 6004 Assessment 2 Policy Proposal

NHS FPX 6004 Assessment 2 Policy Proposal


Capella university

NHS-FPX 6004 Health Care Law and Policy

Prof. Name


Policy Proposal

Mercy Medical Center’s (MMC) performance dashboard evaluation was conducted in the previous assessment, especially related to diabetes screening tests. The dashboard metrics were compared against national benchmarks established by the Agency for Healthcare Research and Quality (AHRQ). The results showed that MMC has underperformed in three diabetes screening tests, which are HgbA1c, eye checks, and foot exams. This paper proposes policy and practice guidelines for MMC to address the underperformance mentioned above and improve the quality of patient care. 

Need for Policy and Practice Guidelines to Address Underperformance 

According to the MMC’s dashboard data, only 35.5% of eye exams were conducted in 2019, which increased to 41% in 2020. However, the national benchmark stays at 75% for all diabetic patients to undergo eye checkups. Similarly, 41.4% and 41.7% of foot examinations were performed in 2019 and 2020, respectively, significantly lower than the national benchmark of 84%. Lastly, the percentage of HgbA1c tests conducted in MMC is 37-48%, whereas according to The National Quality Health Data Registry (NQHDR), the national benchmark is 79.5% (AHRQ, n.d.; Capella University, n.d.). Therefore, the organization must establish and successfully implement policy and practice guidelines to improve patient care, reduce patient safety risks, and augment the organization’s performance. 

Benchmark underperformance in diabetes screening key areas can have significant implications for both the quality of care provided and the overall functioning of the healthcare organization. Lack of screening tests may result in poor management of diabetes, leading to several complications such as kidney disorders, heart diseases, neuropathy, and vision problems (Yahaya et al., 2023). Such issues may diminish patients’ overall health and well-being, eventually questioning the quality of care provided within the organization. Moreover, regularly monitoring these tests is essential for early detection of the signs of complications to prevent through prompt interventions. Underperformance in these areas may lead to missed opportunities for timely interventions and preventive measures, eventually leading to poor patient outcomes (Peer et al., 2020). 

Besides, this shortfall impacts the overall operations within the organization through increased resource utilization and augments financial penalties. Poor patient outcomes may increase emergency visits, hospital stays, and the complexities of diabetes treatment. Thus straining healthcare facilities such as human resources, hospital beds and medical supplies, and hospital finances (Moucheraud et al., 2019). These recurrent hospital visits and admissions can incur additional costs for the organization in the form of penalties and lack of reimbursements, which is another crucial impact on hospital operations’ efficiency. Several repercussions of inaction include diminished patient satisfaction due to lower quality of care, limited healthcare accessibility and amplified healthcare disparities, and non-compliance with regulatory standards and accreditation requirements, potentially imposing legal implications and reputational damage.

Policies and Procedures for the Organization

To address the underperformance of diabetes screening tests, this analysis proposes an organizational policy and related practice guidelines to maintain positive patient outcomes and the organization’s reputation. These policy and practice guidelines are adequately grounded in established benchmarks, as stated earlier by the AHRQ. Moreover, the guidelines by the American Diabetes Association (ADA) and the healthcare policies developed by the Centers for Medicare & Medicaid Services (CMS) support the development of this proposal. One of the policies by CMS is the Affordable Care Act (ACA), which postulates the importance of preventive care to manage chronic healthcare conditions effectively (Marino et al., 2020).

The proposed policy is: Patients with diabetes will have HgbA1c tested every three months until the results are in the targeted range to ensure adequate glycemic control. Similarly, diabetic patients should get their dilated eye examination every one to two years and at least one comprehensive foot examination per year to rule out retinopathy and neuropathy, respectively (ADA, n.d.). However, policy development alone is insufficient and requires practice guidelines for healthcare professionals and other stakeholders to ensure smooth implementation. 

NHS FPX 6004 Assessment 2 Policy Proposal

  • Patient Education: Patient awareness through education is imperative for effective diabetes management. Through this proposal, we aim to motivate healthcare professionals to provide adequate knowledge to diabetic patients on the significance of regular diabetes screening, using clear instructions on test appointments, potential complications, and self-management practices (Chawla et al., 2019). The guidelines stress using easy-to-understand and culturally sensitive educational materials to empower patients in self-managing diabetes and making informed healthcare decisions. 
  • Resource Allocation and Staff Training: Another practice guideline is for hospital administrators to allocate sufficient resources for performing these diabetes screening tests. These practices include the availability of adequate staff, abundant logistics and equipment, and adequate finances. Furthermore, prioritizing healthcare professionals’ training to enhance knowledge about preventive care and management of diabetes motivates patients to bring several behavioral changes (Kime et al., 2020).
  • Community Outreach and Enhanced Healthcare Access: Involving community representatives allows the proposal to expand through community outreach initiatives such as diabetes management awareness sessions. Collaborating with local organizations and health programs to disseminate information, organize educational events, and provide screenings will enhance healthcare access, promoting partnership between MMC and surrounding communities. This expansion assists the organization in addressing healthcare disparities and enhancing accessibility to healthcare resources, ensuring a more holistic and inclusive approach to diabetes management.

Environmental Factors Impacting the Guidelines

Regulatory considerations such as reimbursement policies by CMS significantly impact the practice recommendations. Alterations in these policies may affect resource allocation and staff training programs. Similarly, healthcare laws for data privacy and security, such as the Health Insurance Portability and Accountability Act (HIPAA), influence the use of health information systems and data analytics tools. HIPAA stresses the maintenance of patients’ privacy while sharing and monitoring patient health information (U.S. Department of Health & Human Services, 2022). In our proposed guidelines, this policy is applicable when patient disease process information is shared among concerned stakeholders. Non-compliance with these policies may have potential repercussions, such as diminished hospital reputation and poor legal consequences. 

Besides this, human, logistics, and financial resources are pivotal in shaping and modifying these guidelines. Sufficient staffing is essential to not only perform adequate diabetes screening tests but also provide varied perspectives to ensure patients receive comprehensive care (Sørensen et al., 2020). In our project, an inadequate healthcare workforce affects patient education and the development of community outreach programs. Moreover, fluctuations in funding or budget constraints, lack of hospital beds, minimal transportation services, and reduced community coordination may affect the hospital’s ability to allocate resources and successfully implement the recommended guidelines.

Strategies from the Literature for Ethical Evidence-Based Practice

To improve targeted benchmarks of HgbA1c, eye checks, and foot examinations in diabetic patients, the literature suggests establishing a Multidisciplinary Care Team (MCT). This care team includes endocrinologists, nurses, ophthalmologists, and diabetes specialists. A study by Taïeb et al. (2022) claims a reduction in HgbA1c levels due to an effective MCT approach applied through short hospital stays in diabetic patients. Such a coordinated care approach is aligned with the Affordable Care Act (ACA) postulate, which focuses on improving the quality of care through effective collaboration among interdisciplinary teams.

Moreover, promoting collaborative care respects the principle of patient-centeredness, ensuring that healthcare decisions align with individual values and preferences. This strategy emphasizes the role of administrators to ensure staff is adequately trained about collaborative practices. These training programs also require additional resources, thus impacting stakeholders’ workflow. Moreover, healthcare professionals must manage their jobs to ensure they are effectively trained for these screening tests. 

NHS FPX 6004 Assessment 2 Policy Proposal

Another evidence-based strategy for successfully implementing the proposal is reminder systems. The research mentions that reminder systems, including automated messages or alerts for diabetes screening tests, such as HgbA1c, eye checkups, and foot examinations, significantly improved clinical efficiency and patient appointment compliance rates (Boone et al., 2022). These systems ensure compliance with HIPAA guidelines to protect patients’ privacy through robust security measures such as unauthorized access controls, password protection, and end-to-end encryptions. This strategy follows the ethical principles of autonomy and informed decision.

Moreover, tailoring reminders based on individual preferences promotes inclusivity for diverse cultural norms and practices. Implementing reminder systems may require technological investments, impacting administrators’ jobs to allocate resources. Additionally, increased emphasis on patient communication and education from healthcare professionals may impact time allocation during work hours.

Stakeholders’ Participation in Policies and Guidelines

Stakeholders’ engagement is necessary for developing and successfully implementing the proposed policy and practice guidelines. The stakeholder group includes healthcare professionals who are essential for bringing diverse clinical expertise and providing insights into comprehensive patient care. Their involvement ensures that the policy is grounded in practical knowledge and aligns with the realities of the healthcare landscape (Kime et al., 2020). While the administrators’ role is vital to ensure that the policy aligns with organizational goals, regulatory requirements, and accreditation standards, involving community representatives cultivates a trustworthy environment for the target population, promoting their participation in making the policy and practice guidelines successful. Stakeholder collaboration is essential to create a shared vision and foster a sense of ownership, eventually improving patient outcomes and the organization’s performance. 

Strategies for Collaborating with  Stakeholders

Since stakeholder group engagement is pivotal, it is essential to foster collaboration among stakeholders using two strategies: collaborative workshops and collaborative technology platforms. Collaborative workshops facilitate open discussions to collect insights, combat challenges, and concerns, and modify strategies for implementing policy and practice guidelines (Nickelsen & Bal, 2021). Through these workshops, healthcare professionals can share clinical perspectives, administrators can offer resource allocation insights, and community representatives can contribute to cultural considerations. This active participation ensures the stakeholder group enthusiastically shapes the policy, fostering a sense of ownership and commitment. Moreover, collaborative technology platforms ensure ongoing communication and coordination while bridging communication gaps among the interprofessional team. This strategy aims to introduce shared digital spaces where healthcare professionals, administrators, and community representatives can exchange information and address challenges. This promotes continuous collaboration and ensures that every team member remains informed and involved in the implementation process.


ADA. (n.d.). Health checks for people with diabetes. https://diabetes.org/living-with-diabetes/newly-diagnosed/health-checks-people-with-diabetes 

AHRQ. (n.d.). National Healthcare Quality and Disparities Reports (NHQDR). NHQDR Data Tools | AHRQ Data Tools. https://datatools.ahrq.gov/nhqdr?count=2&tab=nhqdrnabe&type=subtab 

Boone, C. E., Celhay, P., Gertler, P., Gracner, T., & Rodriguez, J. (2022). How scheduling systems with automated appointment reminders improve health clinic efficiency. Journal of Health Economics82, 102598. https://doi.org/10.1016/j.jhealeco.2022.102598 

Capella University. (n.d.). Vila health: Dashboard and health care benchmark evaluation. https://media.capella.edu/CourseMedia/nhs6004element17010/wrapper.asp 

Chawla, S. P. S., Kaur, S., Bharti, A., Garg, R., Kaur, M., Soin, D., Ghosh, A., & Pal, R. (2019). Impact of health education on knowledge, attitude, practices and glycemic control in type 2 diabetes mellitus. Journal of Family Medicine and Primary Care8(1), 261–268. https://doi.org/10.4103/jfmpc.jfmpc_228_18 

Kime, N., Pringle, A., Zwolinsky, S., & Vishnubala, D. (2020). How prepared are healthcare professionals for delivering physical activity guidance to those with diabetes? A formative evaluation. BMC Health Services Research20(1), 8. https://doi.org/10.1186/s12913-019-4852-0 

Marino, M., Angier, H., Springer, R., Valenzuela, S., Hoopes, M., O’Malley, J., Suchocki, A., Heintzman, J., DeVoe, J., & Huguet, N. (2020). The Affordable Care Act: Effects of insurance on diabetes biomarkers. Diabetes Care43(9), 2074–2081. https://doi.org/10.2337/dc19-1571 

NHS FPX 6004 Assessment 2 Policy Proposal

Moucheraud, C., Lenz, C., Latkovic, M., & Wirtz, V. J. (2019). The costs of diabetes treatment in low- and middle-income countries: A systematic review. BMJ Global Health4(1), e001258. https://doi.org/10.1136/bmjgh-2018-001258 

Nickelsen, N. C. M., & Bal, R. (2021). Workshops as tools for developing collaborative practice across professional social worlds in telemonitoring. International Journal of Environmental Research and Public Health18(1), 181. https://doi.org/10.3390/ijerph18010181 

Peer, N., Balakrishna, Y., & Durao, S. (2020). Screening for type 2 diabetes mellitus. The Cochrane Database of Systematic Reviews2020(5), CD005266. https://doi.org/10.1002/14651858.CD005266.pub2 

Sørensen, M., Groven, K. S., Gjelsvik, B., Almendingen, K., & Garnweidner-Holme, L. (2020). The roles of healthcare professionals in diabetes care: A qualitative study in Norwegian general practice. Scandinavian Journal of Primary Health Care38(1), 12–23. https://doi.org/10.1080/02813432.2020.1714145 

Taïeb, A., Gaëlle, L., Roxane, D., Perrine, W., Marion, A., Fleur, B., Zoé, L., Aurélie, L., Solen, D., Patricia, D., & Véronique, A. (2022). Efficiency of a multidisciplinary team care approach through a short hospitalization of patients with poorly controlled diabetes mellitus: A 12 months prospective monocentric study. The Pan African Medical Journal41, 192. https://doi.org/10.11604/pamj.2022.41.192.23965 

NHS FPX 6004 Assessment 2 Policy Proposal

U.S. Department of Health & Human Services. (2022, October 19). Summary of the HIPAA Security Rule. HHS.gov. https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html 

Yahaya, J. J., Doya, I. F., Morgan, E. D., Ngaiza, A. I., & Bintabara, D. (2023). Poor glycemic control and associated factors among patients with type 2 diabetes mellitus: A cross-sectional study. Scientific Reports13(1), 9673. https://doi.org/10.1038/s41598-023-36675-3 

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