NHS FPX 6004 Assessment 2 Policy Proposal

Name

Capella University

NHS-FPX 6004 Health Care Law and Policy

Prof. Name

Date

Policy Proposal

This proposal aims to address the significant shortfall in HgbA1c testing rates at Mercy Medical Center (MMC) by implementing robust policy and practice guidelines. Standardizing testing procedures, enhancing patient education, and providing ongoing provider training will help MMC meet national benchmarks, improve patient outcomes, and ensure regulatory compliance. Effective stakeholder engagement will be crucial in facilitating this transition, providing the guidelines are practical and sustainable. This approach will ultimately enhance the quality of diabetes care and operational efficiency at MMC.

Need for Policy and Practice Guidelines

To address the significant shortfall in meeting benchmark metrics at MMC, particularly in HgbA1c testing rates, it is essential to develop and implement comprehensive policy and practice guidelines. Current benchmarks set by the National Healthcare Quality and Disparities Report (NHQDR) stipulate an HgbA1c testing rate of 84%, but MMC’s data shows only 48% in 2020. This deviation requires immediate corrective measures to improve patient care and meet regulatory standards. The underperformance in HgbA1c testing adversely affects both the quality of care provided and operational efficiency at MMC. Regular HgbA1c testing is crucial for effective diabetes management, helping to monitor glucose control and adjust treatment plans (Eyth & Naik, 2023). Inconsistent testing leads to increased complications and strains of MMC’s resources, resulting in higher emergency room visits and resource allocation issues.

Failing to address these performance shortfalls poses several significant repercussions. Financially, non-compliance with federal and state health regulations could result in reduced funding and financial penalties, impacting MMC’s budget and operations (Crowley et al., 2020). Additionally, inadequate diabetes management can lead to a decline in patient satisfaction and trust, which in turn decreases patient retention and damages the hospital’s reputation. Operationally, increased demand for emergency care due to uncontrolled diabetes pressures hospital resources and complicates service delivery. Persistent benchmark underperformance may jeopardize MMC’s accreditation, affecting its quality of care and operational standards. The NHQDR benchmarks and MMC’s data reveal a significant gap in HgbA1c testing rates, highlighting the need for targeted improvements (Agency for Healthcare Research and Quality, 2022). Studies emphasize the importance of regular HgbA1c testing for managing diabetes effectively and preventing complications (Eyth & Naik, 2023). The operational analysis of fluctuating testing rates and increased emergency visits supports the need for enhanced diabetes management practices to reduce resource strain and improve care quality.

Proposed Organizational Policy and Practice Guidelines

To address the shortfall in meeting the HgbA1c testing benchmark at MMC, a new organizational policy and practice guidelines are proposed. This policy focuses on standardizing HgbA1c testing procedures to ensure consistent and timely testing for all diabetic patients. The guidelines include implementing uniform testing protocols across all departments, enhancing patient education and engagement about the importance of regular HgbA1c testing, and providing ongoing training for healthcare providers to improve adherence to these protocols. A robust monitoring and reporting system will be established to track testing rates and outcomes, ensuring compliance and identifying areas for improvement (Crocker et al., 2020). Additionally, the policy will ensure adequate resource allocation, including staffing and technological support, to facilitate the effective implementation and maintenance of these procedures.

The proposed policy directly addresses benchmarks set by the NHQDR and aligns with federal regulations under the Affordable Care Act (ACA). The NHQDR prescribes a benchmark of 84% compliance for HgbA1c testing rates, while the ACA emphasizes reducing health disparities and improving overall care quality. Adhering to these benchmarks is crucial for meeting federal and state standards and enhancing the quality of diabetes care (Agency for Healthcare Research and Quality, 2022). Several environmental factors influence the MMC’s proposed guidelines. For instance, MMC’s current healthcare infrastructure, including staffing levels and technological resources, plays a critical role in the successful implementation of the new protocols (Senbekov et al., 2020). Adequate resources are necessary to prevent over burdening staff and to ensure the seamless adoption of standardized practices. Additionally, the diverse demographic profile of MMC’s patient population necessitates targeted outreach and education efforts to address any disparities in care.

The cause-and-effect relationships are evident in how the proposed policy will impact care quality. Improved infrastructure and resource allocation are expected to lead to more consistent HgbA1c testing, enhancing patient outcomes and ensuring adherence to federal benchmarks. Enhanced patient education will likely increase adherence to testing schedules, thereby improving overall testing rates and diabetes management (Powers et al., 2020). Moreover, regular provider training will ensure adherence to the new guidelines, resulting in higher compliance rates and better patient care.

Ethical, Evidence-Based Practice Guidelines

To address the shortfall in HgbA1c testing performance at MMC, implementing ethically grounded, evidence-based practice guidelines is essential. Standardized protocols, enhanced provider training, patient education, and real-time monitoring are pivotal for achieving performance improvements and aligning with healthcare policies. Standardizing protocols for HgbA1c testing will establish a consistent framework across all healthcare providers, ensuring equitable and ethically sound care delivery. Evidence supports that this standardization reduces variability, enhances patient outcomes, and aligns with federal regulations like the ACA and state quality benchmarks, ensuring consistent and fair treatment for all patients. Enhanced provider training is crucial, with evidence showing that ongoing, scenario-based education improves adherence to best practices and patient care quality. Focusing on practical applications and current evidence helps MMC meet regulatory requirements and ethical standards (Halliday et al., 2021). This commitment to ethical training and interprofessional collaboration ensures care is based on the latest evidence-based practices.

Patient education is crucial for improving HgbA1c testing compliance, as research shows that informed patients are more likely to adhere to testing schedules and engage in their care. Educational materials must be culturally relevant and accessible to ensure all patients understand the importance of testing (Powers et al., 2020). Empowering patients with knowledge respects their autonomy and aligns with ethical principles of respect, equity, and inclusion, promoting patient-centered care. Implementing real-time continuous glucose monitoring and feedback systems is essential for continuous, ethically responsive performance improvement. Evidence suggests these systems provide actionable insights and facilitate timely adjustments, improving adherence to HgbA1c testing protocols (Reddy & Oliver). By integrating real-time continuous glucose monitoring, MMC can make informed decisions, ensuring care quality, regulatory compliance, and ethical responsiveness to patient needs.

The proposed changes will significantly impact stakeholders by providing providers with more explicit guidelines and enhanced support, leading to improved job satisfaction and reduced care variability. Patients will benefit from more consistent, timely care, likely improving health outcomes and satisfaction (Aldahmashi et al., 2024). Culturally inclusive education will ensure all individuals are respected and supported, aligning with ethical standards of inclusivity and respect for diversity (Reeves et al., 2023). Implementing these guidelines requires careful planning and investment, including funding for training, monitoring systems, and patient education. Addressing financial, staffing, and logistical considerations is crucial for ethical, successful implementation and regulatory compliance.

Stakeholder Involvement

Engaging key stakeholders in developing and implementing the HgbA1c testing guidelines at MMC is crucial for ensuring success and effectiveness. Healthcare providers, patients, administrators, and regulatory bodies each play a vital role in shaping and implementing these guidelines. Healthcare providers are essential for implementing HgbA1c testing protocols, ensuring guidelines are practical and address real-world challenges. Their involvement offers insights, highlights obstacles, and suggests solutions, making guidelines feasible and critical for compliance and improving patient outcomes (Kime et al., 2020). Patients are central to care, and their engagement ensures guidelines are clear, accessible, and culturally relevant, improving adherence and health outcomes. This inclusion respects autonomy, addresses barriers to care, and aligns with ethical principles of equity and respect.

Administrative staff and leadership are essential for aligning the policy with organizational capabilities and resources, ensuring guidelines are feasible and supported. They play a crucial role in resource allocation, policy enforcement, and facilitating training programs, overcoming logistical and financial challenges for the successful implementation of HgbA1c testing protocols. Regulatory bodies and health policymakers must be consulted to ensure guidelines comply with federal, state, and local regulations (Balane et al., 2020). Their involvement aligns the guidelines with legal standards, reducing non-compliance risk and meeting all regulatory requirements. Community and public health representatives should be engaged to address broader public health perspectives. Their input ensures the guidelines support community health goals and preventive care strategies and enhance outreach efforts for widespread adherence (Quinn et al., 2021). Involving these stakeholders ensures a comprehensive approach to policy development, addressing HgbA1c testing shortfalls at MMC. Their input strengthens the policy, aids implementation, and improves patient care.

Strategies for Collaborating with Stakeholders

To implement the proposed policy and practice guidelines for HgbA1c testing at MMC, it is crucial to collaborate strategically with key stakeholders to ensure support, address objections, and incorporate diverse perspectives. Establishing collaborative committees with representatives from healthcare providers, patients, administrative staff, regulatory bodies, and quality improvement teams is essential. These committees will oversee the implementation, provide feedback, and make adjustments, ensuring practical guidelines and fostering smoother integration (Plummer et al., 2021). Joint training sessions for healthcare providers, administrative staff, and patient advocates will facilitate implementation by educating stakeholders about new procedures and addressing challenges. Including patients, representatives ensure that guidelines are culturally inclusive, addressing patients’ needs for more effective implementation. Developing robust feedback mechanisms, such as surveys and focus groups, allows stakeholders to voice concerns and refine guidelines based on real-world feedback (Heckert et al., 2020). This approach addresses issues promptly and helps identify and mitigate objections, providing solutions and clarifications.

Maintaining open and transparent communication with stakeholders is crucial for fostering collaboration and addressing concerns (Pereno & Eriksson, 2020). Regular updates and open forums keep stakeholders informed, and addressing objections with clear explanations of benefits and support will facilitate acceptance and implementation. Providing adequate support and resources, such as staffing, training materials, and technological tools, helps stakeholders adapt to new guidelines. Ensuring these resources reduces resistance and facilitates smoother implementation, demonstrating a commitment to addressing concerns and enhancing effective guideline implementation. Involving stakeholders in developing and implementing the guidelines is vital for success, ensuring practicality, cultural inclusivity, and alignment with real-world needs (Pereno & Eriksson, 2020). Collaboration builds trust, secures buy-in, and addresses objections, leading to more effective and sustainable implementation improving HgbA1c testing performance and patient outcomes at MMC.

Conclusion

The proposed comprehensive guidelines for HgbA1c testing at MMC are vital for bridging the current performance gap and meeting national benchmarks. By standardizing testing procedures, enhancing patient education, and providing targeted provider training, MMC will improve patient outcomes, ensure regulatory compliance, and optimize operational efficiency. Engaging stakeholders throughout the implementation process will foster collaboration, address challenges effectively, and support sustainable improvements in diabetes care. This holistic approach will not only enhance care quality but also strengthen MMC’s overall healthcare delivery and reputation.

References

Agency for healthcare research and quality. (2022). NHQDR Data Tools | AHRQ Data Tools. Datatools.ahrq.gov. https://datatools.ahrq.gov/nhqdr

Aldahmashi, H., Maneze, D., Molloy, L., & Salamonson, Y. (2024). Nurses’ adoption of diabetes clinical practice guidelines in primary care and the impacts on patient outcomes and safety: An integrative review. International Journal of Nursing Studies, 154, 104747–104747. https://doi.org/10.1016/j.ijnurstu.2024.104747

Balane, M. A. (2020). Enhancing the use of stakeholder analysis for policy implementation research: Towards a novel framing and operationalised measures. BMJ Global Health, 5(11), 1–12. https://doi.org/10.1136/bmjgh-2020-002661

Crocker, J. B., Lynch, S. H., Guarino, A. J., & Lewandrowski, K. (2020). The impact of point-of-care hemoglobin A1c testing on population health-based onsite testing adherence: a primary-care quality improvement study. Journal of Diabetes Science and Technology, 15(3), 193229682097275. https://doi.org/10.1177/1932296820972751

Crowley, R., Daniel, H., Cooney, T. G., & Engel, L. S. (2020). Envisioning a better U.S. health care system for all: Coverage and cost of care. Annals of Internal Medicine, 172(2), 7–32. https://doi.org/10.7326/m19-2415

Eyth, E., & Naik, R. (2023). Hemoglobin A1C. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549816/

Halliday, J. A., Speight, J., Green, S. R., O, E., Hagger, V., Morris, A., Sturt, J., & Hendrieckx, C. (2021). Developing a novel diabetes distress e-learning program for diabetes educators: An intervention mapping approach. Translational Behavioral Medicine. https://doi.org/10.1093/tbm/ibaa144

Heckert, A., Forsythe, L. P., Carman, K. L., Frank, L., Hemphill, R., Elstad, E. A., Esmail, L., & Lesch, J. K. (2020). Researchers, patients, and other stakeholders’ perspectives on challenges to and strategies for engagement. Research Involvement and Engagement, 6(1). https://doi.org/10.1186/s40900-020-00227-0

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 Research, 20(1). https://doi.org/10.1186/s12913-019-4852-0

NHS FPX 6004 Assessment 2 Policy Proposal

Pereno, A., & Eriksson, D. (2020). A multi-stakeholder perspective on sustainable healthcare: From 2030 onwards. Futures, 122(2). https://doi.org/10.1016/j.futures.2020.102605

Plummer, C., Ruco, A., Smith, K.-A., Chandler, J., Ash, P., McMillan, S., Di Prospero, L., Morassaei, S., & Nichol, K. (2021). Building capacity in health professionals to conduct quality improvement: Evaluation from a collaborative interorganizational program. Journal of Nursing Care Quality, 36(3), 229–235. https://doi.org/10.1097/NCQ.0000000000000520

Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M., Harms, D., Fischl, A. H., Hooks, B., Isaacs, D., Mandel, E. D., Maryniuk, M. D., Norton, A., Rinker, J., Siminerio, L. M., & Uelmen, S. (2020). Diabetes self-management education and support in adults with type 2 diabetes: A consensus report of the American diabetes association, the association of diabetes care & education specialists, the academy of nutrition and dietetics, the American academy of family physicians, the American academy of Pas, the American association of nurse practitioners, and the American pharmacists association. Journal of the American Pharmacists Association, 60(6), 1–18. https://doi.org/10.1016/j.japh.2020.04.018

Quinn, L. M., Shukla, D., Greenfield, S. M., Barrett, T., Garstang, J., Boardman, F., Litchfield, I., Dayan, C., Gardner, C., Connop, C., Lepley, A., & Narendran, P. (2022). Early Surveillance for Autoimmune diabetes: Protocol for a qualitative study of general population and stakeholder perspectives on screening for type 1 diabetes in the UK (ELSA 1). BMJ Open Diabetes Research and Care, 10(2), e002750. https://doi.org/10.1136/bmjdrc-2021-002750

Reddy, M., & Oliver, N. (2024). The role of real‐time continuous glucose monitoring in diabetes management and how it should link to integrated personalized diabetes management. Diabetes, Obesity and Metabolism, 26(S1), 46–56. https://doi.org/10.1111/dom.15504

NHS FPX 6004 Assessment 2 Policy Proposal

Reeves, J. P., Krezan, C. M., Burge, M. R., Mishra, S. I., Regino, L., Bleecker, M., Perez, D., McGrew, H. C., Bearer, E. L., & Erhardt, E. (2023). A patient-centered comparative effectiveness research study of culturally appropriate options for diabetes self-management. MedRxiv. https://doi.org/10.1101/2023.01.31.23285236

Senbekov, M., Saliev, T., Bukeyeva, Z., Almabayeva, A., Zhanaliyeva, M., Aitenova, N., Toishibekov, Y., & Fakhradiyev, I. (2020). The recent progress and applications of digital technologies in healthcare: A review. International Journal of Telemedicine and Applications, 2020(1), 1–18. https://doi.org/10.1155/2020/8830200