NHS FPX 6004 Assessment 3 Training Session for Policy Implementation

Name

Capella University

NHS-FPX 6004 Health Care Law and Policy

Prof. Name

Date

Training Session for Policy Implementation

Welcome and Introduction 

Hello, and thank you for participating in this significant training session. Today, we go on a journey to advance our understanding and practices in diabetes care at Mercy Medical Center (MMC). As dedicated healthcare professionals, our primary goal is to provide exceptional care and improve our patients’ well-being. This session represents a crucial step in enhancing our strategies to support better those we serve.

Purpose of the Training 

This training will introduce you to the newly developed policy and practice guidelines for diabetes management. These strategies represent a significant advancement in our care procedures, aligning with the latest standards for patient care and diabetes management.

What to Expect

During this training session, we will address diabetic patient care at MMC to improve compliance with regulations and enhance patient outcomes. By implementing evidence-based policy and practice guidelines, we can make significant strides in diabetes management. Our strategy includes vital initiatives such as standardized protocols to ensure all patients receive the same high standard of care, staff training programs to keep our team informed on the latest diabetes management techniques and guidelines, and patient education initiatives to empower patients with the knowledge they need to manage their diabetes effectively. Currently, only 48% of our diabetic patients had their HgbA1c tested, 41% had their eyes screened, and 41.7% received foot exams, all of which fall short of the NHQDR goals (NHQDR, 2022). To address this, we will leverage our electronic health record (EHR) systems to track patient screenings better and ensure comprehensive diabetes management. Through these efforts, MMC is committed to improving diabetic patient care and aligning with NHQDR benchmarks while upholding ethical healthcare standards.

Our Goal for Today

 This session aims to ensure you are confident and skilled in implementing the updated guidelines. We seek to enhance your expertise and empower you to provide exceptional care to our diabetes patients. This training is an opportunity for professional growth and reflects our continued commitment to excellence in healthcare. Let’s embark on this journey focusing on learning, improvement, and a steadfast commitment to delivering quality patient care.

Strategies for the Role Group for Policy Implementation and Promoting Buy-In

Based on the assessment of MMC diabetes care deficiencies, evidence-based strategies for obtaining buy-in and preparing healthcare providers to implement new policies and practice guidelines are Regular education and training sessions to familiarize healthcare providers with new policies and practice guidelines, covering rationale, importance, and implementation. Success indicators include increased participation, positive feedback, high adherence, and improved key performance indicators related to diabetes care, such as foot exams, HgbA1c testing, and eye screenings, signaling better patient outcomes and care quality aligned with the National Healthcare Quality and Disparities Report (NHQDR) benchmarks. Continuous monitoring and feedback incorporation ensure ongoing refinement and optimization of guideline implementation strategies (Zou et al., 2020).

Healthcare providers’ feedback is actively incorporated into the implementation plan to address their concerns and ensure alignment with their needs. This collaborative approach fosters a sense of ownership and buy-in among healthcare providers, as they feel their voices are heard and valued. Additionally, adjusting the implementation plan based on their feedback increases the likelihood of successful adoption and adherence to the guidelines. Early indications of success may include increased participation and engagement in education and training sessions among healthcare providers and improvement in key performance indicators related to diabetes care, such as increased rates of foot exams, HgbA1c testing, and eye screenings, indicating better patient outcomes and quality of care in line with NHQDR targets (Petkovic et al., 2020).

Establish mechanisms for tracking compliance with the new guidelines, such as electronic health record systems or manual audits. Performance monitoring systems track adherence to guidelines, enabling timely interventions. Ongoing support, like additional training or resources, reinforces providers’ commitment. Early success indicators include increased participation in sessions, positive feedback, high adherence, and improved key performance indicators in diabetes care, signaling better patient outcomes and alignment with NHQDR standards (Oyugi et al., 2020). These strategies collectively signify success in obtaining buy-in from healthcare providers and effectively implementing practice guidelines and the new policy.

Practice Guidelines and New Policy Impact on Healthcare Providers

Implementing the practice guidelines and new policy at MMC will considerably impact the healthcare provider role group’s daily work routines and responsibilities, including physicians, nurses, and other staff involved in diabetes care. The new guidelines emphasize the importance of regular screenings, such as HgbA1c testing, foot exams, and eye screenings, to improve patient outcomes and comply with regulatory benchmarks. Healthcare providers must integrate these screenings into their daily routines, ensuring that each patient receives timely and appropriate care according to the new policy and practice guidelines. This may require adjustments to scheduling practices to accommodate additional screening appointments and allocate sufficient time for thorough examinations (Carmichael et al., 2021). Furthermore, healthcare providers will undergo comprehensive education and training sessions to familiarize themselves with the rationale behind the new policy and practice guidelines and the specific procedures to follow. Hands-on practice and simulations will enhance their skills in performing the required screenings accurately and efficiently (Zou et al., 2020).

Implementing electronic health record systems will facilitate tracking patient screenings and identifying individuals needing follow-up care. Healthcare providers must adapt to using these systems effectively, ensuring accurate documentation of patient encounters and adherence to screening protocols (Oyugi et al., 2020). By adhering to the new policy and practice guidelines, healthcare providers at MMC will be better equipped to meet the NHQDR targets, significantly improving the quality of diabetes care. This comprehensive approach ensures that MMC aligns with federal healthcare quality benchmarks, ultimately enhancing patient outcomes and fostering a culture of continuous improvement and excellence in patient care.

Justification of Practice Guidelines and New Policy for Healthcare Providers

Implementing practice guidelines and the new policy at MMC signifies a pivotal advancement in addressing deficiencies in diabetes care benchmarks, precisely aligned with the NHQDR targets. These guidelines directly address the critical shortfall in HgbA1c testing, foot exams, and eye screenings, essential for managing diabetes effectively and improving patient outcomes. The new policy and practice guidelines require healthcare providers to integrate regular screenings into daily routines. This includes HgbA1c testing to monitor blood glucose levels, foot exams to prevent ulcers and infections, and eye screenings to detect diabetic retinopathy early. By adhering to these guidelines, healthcare providers will ensure that MMC meets NHQDR targets to increase the quality of diabetes care and reduce associated complications (Sivakumar et al., 2023).

The guidelines emphasize patient education and engagement. Healthcare providers will conduct tailored education initiatives, helping patients understand the importance of regular screenings and self-care practices. This empowerment leads to better adherence to treatment plans and lifestyle modifications, directly contributing to improved health outcomes and alignment with NHQDR benchmarks (He et al., 2023). Implementing electronic health record systems is another crucial aspect of the new policy and practice guidelines. These systems facilitate seamless patient screenings and follow-up care tracking, ensuring that healthcare providers can monitor compliance with NHQDR targets. Efficient data management and communication through these systems will streamline patient care processes, enhancing overall efficiency and effectiveness (Oyugi et al., 2020).

MMC’s new policy and practice guidelines provide a comprehensive framework for delivering evidence-based, patient-centered care. They address deficiencies highlighted by NHQDR, promote proactive screening and management practices, and foster patient engagement, all contributing to better health outcomes. This detailed integration justifies their importance in improving care quality for diabetic patients. Adhering to these guidelines enhances healthcare providers’ daily routines, improves compliance with federal benchmarks, and ultimately fosters improved patient health and well-being.

Role Group’s Significance in Implementing Practice Guidelines and New Policy

The selected role group at MMC, comprising healthcare providers directly involved in diabetes care, such as physicians, nurses, and support staff, is significant in implementing practice guidelines and the new policy. Their direct contact with patients and integral role in delivering diabetes care make their buy-in and active involvement essential for successful guideline implementation. Specifically, physicians are responsible for diagnosing diabetes, prescribing treatments, and overseeing patient care plans. Nurses are crucial in administering treatments, conducting screenings, and providing patient education. Support staff contribute to the efficient functioning of diabetes care processes, such as scheduling appointments and maintaining patient records. With the commitment and buy-in of these healthcare providers, the successful implementation of the new policy and practice guidelines would be maintained (Sibbald et al., 2020).

To empower the role group during implementation, it is imperative to emphasize the helpful impact of their assistance on patient outcomes and overall healthcare value. This can be achieved by highlighting success stories where adherence to similar guidelines improved patient health and satisfaction. Additionally, involving healthcare providers in decision-making processes, such as determining implementation strategies and protocols, fosters a sense of ownership and accountability (Sørensen et al., 2020). Providing continuous education and training opportunities tailored to the specific needs of each role within the group ensures that healthcare providers feel equipped and confident in implementing the new guidelines (Zou et al., 2020). Recognizing and celebrating their achievements and milestones throughout the implementation process reinforces their importance and encourages continued dedication to delivering high-quality diabetes care at MMC.

Determining Instructional Content, Activities, and Materials for Training Healthcare Providers

During the initial segment of the training session, applicants will be introduced to the rationale behind the new policy and practice guidelines for diabetes care at MMC. Through engaging presentation slides, healthcare providers will gain insights into the significance of complying with NHQDR benchmarks, emphasizing the importance of adherence to the guidelines. This interactive discussion will facilitate a deeper understanding of the guidelines, fostering buy-in and commitment from participants to ensure successful implementation. Following the introduction, a thorough overview of screening procedures will be provided, including HgbA1c testing, foot exams, and eye screenings. Healthcare providers will understand these screenings’ crucial role in diabetes management through explanations and visual aids.

Subsequently, participants will perform role-playing scenarios to practice conducting screenings on simulated patients, fostering skill development and confidence (Sivakumar et al., 2023). Participants will receive training on utilizing electronic health record systems for documenting screenings and tracking patient care. Through live demonstrations and hands-on practice sessions, healthcare providers will familiarize themselves with the system’s functionalities, ensuring seamless integration into their workflows. Proficiency in electronic health record systems is vital for tracking compliance and facilitating efficient patient care management (Oyugi et al., 2020). Effective patient education is crucial for diabetes care initiatives. Healthcare providers will explore strategies for educating patients about screenings and self-care practices. Through brainstorming, participants will develop tailored patient education materials. This segment aims to enhance patient engagement and treatment plan adherence (He et al., 2023).

Conclusion of Training Session

To conclude the training session, a devoted Q&A session will allow participants to seek clarification on any remaining questions or concerns. Facilitators will address inquiries and summarize key takeaways from the training, reinforcing critical concepts discussed throughout the session. This open forum guarantees that healthcare providers break the training session with a clear understanding of their roles and responsibilities in implementing the new policy and practice guidelines at MMC. It also encourages active participation. Regarding the duration, the proposed activities can be completed within the allotted two hours, provided that time is managed effectively and each segment is placed appropriately to cover all essential content comprehensively.

References

Carmichael, J., Fadavi, H., Ishibashi, F., Shore, A. C., & Tavakoli, M. (2021). Advances in screening, early diagnosis and accurate staging of diabetic neuropathy. Frontiers in Endocrinology, 12, 671257. https://doi.org/10.3389/fendo.2021.671257 

He, Q., Chen, X., & Zeh, P. (2023). He-Promoting Self-care and Management for Patients With T2D 302 Alternative Therapies. Alternative Therapies in Health and Medicine, 29(5). http://www.alternative-therapies.com/oa/pdf/8182.pdf 

NHQDR. (2022). NHQDR Data Tools | AHRQ Data Tools. Datatools.ahrq.gov. https://datatools.ahrq.gov/nhqdr 

Oyugi, B., Makunja, S., Kabuti, W., Nyongesa, C., Schömburg, M., Kibe, V., Chege, M., Gathu, S., Wanyee, S., & Sahal, M. (2020). Improving the management of hypertension and diabetes: An implementation evaluation of an electronic medical record system in Nairobi County, Kenya. International Journal of Medical Informatics, 141, 104220. https://doi.org/10.1016/j.ijmedinf.2020.104220 

Petkovic, J., Riddle, A., Akl, E. A., Khabsa, J., Lytvyn, L., Atwere, P., Campbell, P., Chalkidou, K., Chang, S. M., Crowe, S., Dans, L., Jardali, F. E., Ghersi, D., Graham, I. D., Grant, S., Smith, R. G., Guise, J.-M., Hazlewood, G., Jull, J., & Katikireddi, S. V. (2020). Protocol for the development of guidance for stakeholder engagement in health and healthcare guideline development and implementation. Systematic Reviews, 9(21), 1–11. https://doi.org/10.1186/s13643-020-1272-5 

Sibbald, S. L., Ziegler, B. R., Maskell, R., & Schouten, K. (2020). Implementation of interprofessional team-based care: A cross-case analysis. Journal of Interprofessional Care, 1–8. https://doi.org/10.1080/13561820.2020.1803228 

NHS FPX 6004 Assessment 3 Training Session for Policy Implementation

Sivakumar, P. M., Prasad, R., & Prabhakar, P. K. (2023). Editorial: Advanced approaches in the diagnosis and treatment of diabetes mellitus and secondary complications. Frontiers in Endocrinology, 14. https://doi.org/10.3389/fendo.2023.1291637 

Sørensen, M., Groven, K. S., Gjelsvik, B., Almendingen, K., & Holme, L. G. (2020). The roles of healthcare professionals in diabetes care: A qualitative study in Norwegian general practice. Scandinavian Journal of Primary Health Care, 38(1), 12–23. https://doi.org/10.1080/02813432.2020.1714145 

Zou, G., Witter, S., Caperon, L., Walley, J., Cheedella, K., Senesi, R. G. B., & Wurie, H. R. (2020). Adapting and implementing training, guidelines and treatment cards to improve primary care-based hypertension and diabetes management in a fragile context: Results of a feasibility study in Sierra Leone. BMC Public Health, 20(1). https://doi.org/10.1186/s12889-020-09263-7 

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 

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Name

Capella University

NHS-FPX 6004 Health Care Law and Policy

Prof. Name

Date

Dashboard Metrics Evaluation

Mercy Medical Center’s (MMC) diabetes care dashboard reveals critical areas of underperformance, particularly in HgbA1c exams, foot exams, and eye exams. Inconsistent and declining metrics in these areas highlight significant gaps in diabetes management and adherence to local, state, and federal benchmarks. The impact of these deficiencies extends beyond patient outcomes, affecting MMC’s reputation, resource allocation, and staffing efficiency. Addressing these issues requires a coordinated, ethical approach involving diverse stakeholders to improve care quality, ensure equitable access, and implement sustainable practices.

Evaluate Dashboard – Underperforming Metrics

 MMC diabetes dashboard provides a comprehensive overview of their performance against various benchmarks set forth by local, state, and federal health care policies. Analyzing this data reveals areas where the organization excels and areas where improvement is necessary to meet these benchmarks. Notably, the metrics for HgbA1c exams and foot exams could be performing better. HgbA1c exams, crucial for monitoring long-term blood glucose control in diabetic patients, have shown inconsistent and generally declining numbers. For instance, the number of HgbA1c exams was 60 in Q1 2019 but fluctuated and reached only 64 by Q4 2020. Similarly, foot exams, which are vital for preventing diabetic foot complications, are underperforming. Despite a peak of 75 in Q1 2020, the numbers dipped to 48 in Q3 2020 and only slightly improved to 62 by Q4 2020. These fluctuations indicate a need for consistent adherence to the recommended screening protocols. Eye exams, a critical metric for diabetic patients due to retinopathy risk, fluctuated: 50 in Q1 2019, 42 in Q4 2019, and 64 by Q4 2020. These variations indicate potential gaps in monitoring and follow-up, risking undiagnosed complications (NHDQR, 2022).

Local, state, and federal policies stress regular screenings and preventative care for managing diabetes, with the Centers for Medicare & Medicaid Services (CMS) setting benchmarks for quality care. Diabetic patients should have at least two HgbA1c tests per year if stable and annual foot and eye exams (Kollipara et al., 2021). The declining and inconsistent numbers at MMC indicate that these benchmarks need to be consistently met, highlighting a significant area for improvement. The evaluation shows MMC needs to stabilize and increase the frequency of HgbA1c, foot, and eye exams to meet health care benchmarks. Inconsistent performance could lead to undiagnosed complications and poorer outcomes, impacting overall care quality. Addressing these issues could improve patient outcomes, enhance compliance with healthcare laws, and boost patient satisfaction and trust. Several unknowns and areas of uncertainty affect the evaluation’s completeness for MMC. The dashboard needs to include data on the total number of new patients per quarter, making it hard to identify trends. There is also no comparative data from similar facilities for accurate benchmarking and no detailed demographic data on patients, which could reveal disparities in care. Enhancing data availability, including detailed demographics, comparative benchmarks, and historical patient data, would improve the evaluation process for MMC.

Consequences of Not Meeting Prescribed Benchmarks

MMC’s failure to meet benchmarks for HgbA1c, foot, and eye exams has significant impacts, compromising its mission for high-quality care and vision of excellence. This deficit risks diminishing MMC’s reputation and its standing in consumer awards and other recognitions. Allocation of resources is heavily impacted by benchmark underperformance, as inefficiencies in diabetes care require additional investments, straining financial resources. This misalignment may lead to increased budgetary expenditures and affect overall efficiency (Sin et al., 2020). Inadequate performance also influences staffing needs, as the organization may require hiring additional specialized staff, such as diabetes educators or care coordinators, and increasing workloads for existing staff. This may lead to exhaustion and decreased morale, affecting the quality of care (Alshammari et al., 2021). Financially, not meeting benchmarks leads to increased operational costs from complications like readmissions and emergency interventions. Underperformance can also affect eligibility for federal financial incentives tied to performance metrics. This may result in reduced operational and capital funding, impacting MMC’s overall financial stability.  Logistically, the need for additional resources or expanded facilities can strain existing space and disrupt operational efficiency. Increased demand for support services, like pharmacy and dietary, due to underperformance can lead to delays and reduced quality, affecting patient care (Garcia et al., 2022).  

Cultural competency is critical as MMC serves a diverse community, and benchmark underperformance may exacerbate health disparities in certain demographic groups. Tailoring care to meet cultural and linguistic needs is essential for effective diabetes management and equitable care delivery (Joo & Liu, 2020). Staff skills and training are crucial, as benchmark underperformance may reveal gaps in staff preparedness for exams or managing diabetic patients. Investing in comprehensive training is vital for improving care quality and achieving benchmark compliance (Kime et al., 2020). Procedural and process inefficiencies, such as irregular exam scheduling and lack of standardized follow-up protocols, contribute to benchmark underperformance. Revising and standardizing these procedures is essential for consistent performance and improved care quality. Challenges contributing to benchmark deficits include inadequate patient follow-up systems, insufficient staff training, resource constraints, and logistical issues. Cultural and language barriers may also impact patient adherence to care protocols (Kvarnström et al., 2021). The analysis assumes benchmarks accurately indicate care standards and that the dashboard data reflects performance. It also presumes addressing gaps in resources, staffing, and procedures will improve performance and compliance.

Evaluating a Key Benchmark Underperformance

Among the metrics for diabetes management at Mercy Medical Center (MMC), HgbA1c exam underperformance presents the most critical opportunity for improving quality and performance. Irregular and declining numbers, fluctuating from 60 in Q1 2019 to 64 by Q4 2020, reflect a troubling inconsistency undermining effective diabetes management. This issue is the most widespread throughout MMC’s diabetes care system. While foot and eye exams also show variability, the HgbA1c metric stands out due to its central role in long-term diabetes management and its broader implications for patient care. Inconsistent HgbA1c testing directly impacts a large portion of the diabetic population, leading to inadequate disease monitoring and potentially severe health complications (Boye et al., 2022).

The underperformance in HgbA1c exams has significant repercussions for the community served by MMC. Uncontrolled diabetes, due to infrequent or irregular HgbA1c/ HbA1c testing, can result in an increased incidence of complications such as cardiovascular disease, neuropathy, and nephropathy. These complications not only deteriorate patients’ quality of life but also escalate medical costs and place additional strain on local healthcare resources (Khor et al., 2023). Consequently, addressing this benchmark shortfall is crucial for mitigating these adverse outcomes and improving community health. Focusing on enhancing HgbA1c exam performance offers the most incredible opportunity to elevate MMC’s overall quality of care. By stabilizing and increasing the frequency of HgbA1c testing, MMC can enhance its diabetes management practices, leading to earlier detection of complications, better disease control, and ultimately improved patient outcomes (Chen et al., 2023). This improvement will align MMC with established benchmarks and reinforce its commitment to high-quality care and patient satisfaction.

Advocating for Ethical and Sustainable Actions

To address the underperformance in HgbA1c exams at MMC, a coordinated approach involving a diverse group of stakeholders is crucial. The primary stakeholders include the diabetes care team, which is comprised of endocrinologists, diabetes educators, primary care physicians, nursing staff, and hospital administration and health policymakers. This group is essential because they each play a significant role in managing, monitoring, and improving diabetes care practices at MMC. The diabetes care team is directly involved in patient management and is responsible for ensuring the consistent performance of HgbA1c tests. Their daily interactions with patients make them ideally suited to implement changes and monitor improvements (Vitale et al., 2020). Hospital administration can facilitate systemic changes, such as updating protocols and allocating resources for staff training. Health policymakers can ensure alignment with regulatory standards and support for necessary interventions through funding and policy adjustments (Schillinger et al., 2023).

Ethical actions for this stakeholder group at MMC involve several vital considerations. First, a patient-centered approach should be prioritized, emphasizing the importance of regular HgbA1c testing for effective diabetes management. This includes ensuring that patients at MMC are well-informed about the significance of these tests and providing support to help them adhere to recommended testing schedules (Kalyani et al., 2024). Additionally, addressing equitable access to care is crucial. MMC must ensure that all patients, regardless of their socio-economic status, have access to necessary testing and follow-up care. This involves providing educational resources and support tailored to diverse patient populations to prevent disparities in diabetes care. Transparency and accountability are also vital. Implementing regular audits and transparent reporting on HgbA1c testing performance at MMC will help maintain accountability and build trust with patients and the community (Murfet, 2021). Furthermore, integrating sustainable practices into care protocols at MMC is essential. This includes developing efficient testing procedures and resource management strategies to ensure that interventions are cost-effective and sustainable over time. Finally, ongoing training and support for healthcare professionals are critical. By providing up-to-date training on best practices in diabetes management and support to prevent staff burnout (Yao et al., 2021). By addressing these ethical and sustainable actions, MMC can enhance its performance on HgbA1c benchmarks, improve patient outcomes, and foster a culture of excellence and equity in diabetes care.

Conclusion

To address MMC underperformance in HgbA1c, foot, and eye exams, it is crucial to implement targeted interventions that stabilize and enhance these metrics. By improving data collection, streamlining procedures, and investing in staff training, MMC can better meet healthcare benchmarks and to improve patient outcomes. These actions will not only resolve operational and financial challenges but also promote equitable and sustainable practices. Ultimately, addressing these issues will strengthen MMC’s commitment to high-quality, patient-centered care and improve overall care quality and efficiency.

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