NURS FPX 6004 Assessment 2 Policy Proposal

NURS FPX 6004 Assessment 2 Policy Proposal

NURS FPX 6004 Assessment 2 Policy Proposal

Healthcare organizations increasingly employ benchmarking to save costs and improve product and service quality by comparing themselves to an industry standard, a peer organization, or an external benchmark. Benchmarking is an important feature of quality management since it allows companies to constantly evaluate how they stack up against industry leaders (Purushotham et al., 2018).

Improving the quality of treatment while remaining competitive in the market and within ever-tighter budgets is a challenge that today’s healthcare executives must address. Performance may be measured against benchmarks that represent industry best practices (Imboden et al., 2020). In hospitals, these benchmarks are used to measure performance against those of similar facilities and national organizations. Instead of comparing hospitals against one another, as is done in competitive benchmarking, hospitals engage in collaborative benchmarking to improve their overall performance in a certain area (Imboden et al., 2020).

The Mercy Medical Center in Minnesota is consistently ranked as one of the top hospitals in the United States (Vila Health, 2018). To accomplish ambitious objectives and to keep its place as one of the best medical coverage programs in the country, it must continue to push itself. Nevertheless, it is of the utmost importance that the hospital abides by all of the necessary legislation on the national, state, and local levels. The dashboard was used to create metrics to conduct a study of guidelines for diagnosing and treating diabetes. We can evaluate performance using these measures, get insight into areas in which we may be able to make changes, and raise the bar for quality. This paper aims to provide policy and practice recommendations to resolve a deficiency in fulfilling a benchmark, as well as evidence-based, practice guidelines to enhance the performance of a targeted benchmark. In addition to that, the relevance of stakeholder engagement as well as the effect of environmental factors on practice standards will be investigated throughout this paper.

Need for Creating a Policy and Practice Guidelines

Current Benchmark for the Organization

The statistics from the dashboard reveal concerns over a fall in HgbA1c tests as well as a simultaneous decrease in foot inspections. Both of these trends are concerning. According to the MMC dashboard, the number of inspections dropped dramatically between the first and fourth quarters. The frequency of HbA1c checks and foot examinations has dropped by 95% (Vila Health, 2018). According to the findings of the National Healthcare Quality and Disparity Report, patients with diabetes who received diabetic foot care and patient education as a component of their short-stay home health care fulfilled national objectives at a rate of 98.6 % (National Healthcare Quality and Disparity Report, 2020). This fraction also takes into account diabetic patients who were at least 40 years old and who had at least two hemoglobin A1c tests carried out during the corresponding fiscal year (National Healthcare Quality and Disparity Report, 2020). The achievement of a value that is at least 90% of the value of the benchmark would be considered a successful effort for MMC.

 Effect of Benchmark Underperformance

Patients diagnosed with diabetes need a comprehensive treatment plan that is carried out by a group of medical professionals who are specialists in their respective disciplines. HbA1c testing and diabetic foot exams are very necessary to aid patients in managing their disease for a longer period and to discover potential issues associated with diabetes at an earlier stage (Manu et al., 2018). Screening for diabetic foot issues, which may result in permanent impairment or even death, is thus regarded as a crucial component of the management of diabetes. According to the American Diabetes Association (ADA), testing for hemoglobin A1c is one of the most common methods used in diabetes screening and is regarded as an essential component of diabetes therapy and management, thus MMC should raise the bar of quality and make policies to resolve the underperforming benchmarks (Manu et al., 2018).

Repercussions of not making any Changes

The increased financial burden and decreased quality of life would be experienced by diabetic patients as a direct result of inadequate treatment standards for diabetes (American Diabetes Association, 2020). Careful management of patients suffering from this condition is required for MMC to continue to provide high-quality treatment and to retain its position as one of the premier healthcare facilities in the state (Vila Health, 2018). Type 2 diabetics have their blood sugar checked regularly to monitor their condition and detect any issues early on. As an immediate short-term indication, blood glucose tests and foot examinations may be utilized (Imai et al., 2021). HbA1c testing has become the standard of care for keeping tabs on and managing T2DM. ischemic heart disease (IHD), foot ulcers, and chronic renal disease are some of the consequences that might arise if HbA1c levels are not monitored or foot examinations are not thoroughly done (Imai et al., 2021).

Evidence-Based Practice Guidelines

Evidence-Based Literature

According to the management at MMC, the processes for diagnosing and treating diabetes at the facility need to undergo some modernization. The dashboards indicate that there may be a flaw in the screening criteria, as there is a drastic drop in screening rates. This flaw is indicated by the fact that screening rates have fallen dramatically. Probably, some of the 5 physicians engaged in this case might not have the appropriate training to manage diabetes. Along with regular monitoring, medication, and counseling, the American Diabetes Association (ADA) suggests that clinicians instruct their type 2 diabetes patients about the condition and how it may be prevented in addition to providing these services (Powers et al., 2020). Additionally, nurses and providers should provide culturally competent care (Powers et al., 2020). Since T2DM often presents with no or mild symptoms initially, it may be difficult to diagnose. It is possible that the onset of type 2 diabetes mellitus and its complications may be avoided or at least delayed if the condition is diagnosed and treated early in otherwise healthy people (Peer et al., 2020).

Local, State or Federal Healthcare Policy

To make progress and meet the standards established by federal, state, and local governments, evidence-based procedures must be implemented. One of these tactics is using a Chronic Care Model (CCM) that has improved healthcare results (Boehmer et al., 2018). With the aid of this method, the standards for treating and managing diabetes have been achieved. The use of the CCM in combination with the diabetic algorithm helps to prevent any gaps in treatment from occurring (Boehmer et al., 2018). Current difficulties, remote access and opulent inquiries, diabetes education, medication, and follow-up plans with timelines are all documented, as are recent meetings, test results, and impending tests that need to be looked at. Both doctors at MMC may benefit from this method since it would guarantee thorough and regular follow-up screenings and the delivery of the diabetes care package. Investigations demonstrate that between 32% to 35% of persons had an A1c of less than 7% when using such models (Kutz et al., 2018).

Application of these Strategies in the Context of MMC

According to the MMC website, the corporation may stand to gain from an increase in the number of patients who are successful in communicating with their clinicians during outpatient appointments. The dashboard data has shown two significant concerns; both are associated with preventative medications that are most effectively delivered in an outpatient environment, most of the time under the supervision of the patient’s primary care physician. The strengthening of already established baselines is one of the many possible advantages that might be gained by creating a clinic or unit at MMC that would be entirely dedicated to the provision of diabetes care packages. An annual diabetic foot exam is recommended for those who have impaired fasting glucose, and those who have diabetes should have at least one to two hemoglobin A1c readings per year. Kutz et al. (2018), emphasize that following the guidelines of the American Diabetes Association for diabetic care packages and medications may not only be helpful from a monetary standpoint but also may lower the risk of significant complications arising from the management and treatment of diabetes (Kutz et al., 2018). Additionally, it is a must to train providers on respecting the diversity of patients (McGregor et al., 2019).

Ethical and Cultural Validation of Strategies

The cultural and ethical values of all people are taken into account while developing these plans. By interacting with patients in an ethical manner, which is made possible via training employees to respect different cultures, we can guarantee that every kind of patient has been examined (McGregor et al., 2019). As a result, they will treat patients of all backgrounds with dignity and without prejudice. The staff’s approach to patients will be guided by the values of kindness, respect for individual agency, and fairness. Patients of all backgrounds and socioeconomic statuses will be treated with the same dedication and care. The results will be better this way (McGregor et al., 2019)

Potential Effects of Environmental Factors

The practices and processes that are used to improve healthcare quality may be affected by the setting in which they are carried out. The laws of the FDA (Food and Drug Administration) and the ACA (Affordable Care Act), in addition to the financial stability and resources of the organization, the engagement and collaboration of healthcare professionals, the acceptance level of patients, the age of patients, and other factors, all play a role in the process.

Regulatory Considerations

If a person follows the guidelines for their food, amount of activity, blood sugar, and blood pressure, there is a chance that their health will improve. The provisions of the Affordable Care Act also have a significant influence on the battle to reduce the prevalence of diabetes and improve its management. The objective of preventing diabetes has been achieved along with these rules. These mandates have sought to improve diabetes outcomes by facilitating the provision of social assistance, insurance services, and educational opportunities (Furmanchuk et al., 2021). In a nutshell, Mercy Medical Center may be able to raise treatment quality and increase patient satisfaction with the help of the regulatory system in place there.


The first factor to take into account is Shakopee’s age demographics, which show that 23.9% of the city’s residents are over the age of 44 (Vila Health, 2018). According to research that was carried out between 2010 and 2016 and then published by Davidson et al. (2021), it was discovered that pre-diabetes was found in around 25% of Americans aged 40-74 (Davidson et al., 2021). These findings demonstrate beyond a reasonable doubt that a significant portion of the general population is at an increased risk for acquiring diabetes. It is vital that screening and 8 follow-up treatments for a significant number of patients be emphasized because this age group accounts for more than a quarter of the population (Davidson et al., 2021). Additionally, it is very necessary to have a clinical staff that is big enough to support the diabetes treatment package for such a huge population.

The norms and standards may be altered by factors such as the number of funds that are accessible. Without appropriate financial assistance, the initiatives cannot be put into action. Additionally, the set goals can be achieved, but only if there is enough supply of both labor and tools. The actions of the workers are another factor that contributes to the effectiveness of the offered methods. Cooperation and buy-in from staff members are essential to the success of these initiatives. One further thing to take into consideration is the amount of time that will be necessary to put the new regulations into effect. The education of the clinic’s employees is one of the most important factors in determining how successful the clinic will be. It is correct to say that a cost-benefit analysis is essential to the successful implementation of the new processes.

Importance of Stakeholders Engagement

Diabetic treatment should be implemented by a team overseen by a physician. Teams with this focus and expertise may include but are not limited to doctors, nurses, dietitians, pharmacists, and psychologists. The A1C test is used to evaluate the efficacy of diabetic therapies by measuring the median glycemia of patients over the past 2-3 months (Imai et al., 2021). To document the degree of glycemic control at the time of first evaluation and afterward monitor the patient’s success in controlling their diabetes, A1C testing is required regularly (Imai et al., 2021). Each patient’s blood glucose control should be evaluated every three months using the A1C test to see whether it has improved and is staying within the target range; however, this schedule may be improved only when the relevant stakeholders are engaged and the treatment strategy utilized (Imai et al., 2021). The Guidelines for Diabetic Care urge a thorough approach for diabetic patients’ feet, especially those with a history of previous ulceration or amputation by physicians.

NURS FPX 6004 Assessment 2 Policy Proposal

Diabetics should get a complete checkup of their feet once a year to look for any symptoms of infection or other issues that might result in the need for amputation in the future. Every consultation should begin with a visual examination of the patient’s foot, followed by testing with the Semmes-Weinstein monofilament and palpation (Kaya & Karaca, 2018). People who are at high risk for developing diabetic foot ulcers should maintain continuous communication with a foot care professional who can offer both preventative therapy and ongoing monitoring. Due to the complexity of the condition, primary care physicians and hospital doctors need to have sufficient training in diabetes treatment and assessment procedures (Kaya & Karaca, 2018). People who are at high risk for developing diabetic foot ulcers should maintain continuous communication with a foot care professional who can offer both preventative therapy and ongoing monitoring. Due to the complexity of the condition, primary care doctors and nurses must have proper training in diabetes treatment and assessment procedures (Kaya & Karaca, 2018).

Stronger Policy

A team-based strategy will be used by the healthcare practitioner. In this approach, collaboration among medical professionals, nurses, dietitians, financial managers, stakeholders, and executive staff will be essential (American Diabetes Association, 2020). The treatment and prevention of diabetes will be significantly hampered without their involvement and cooperation. Patients will get information on how to apply all of the critical measures in diabetes treatment as well as encouragement to engage in regular testing. Patients will also assist organizations in accomplishing their objectives if they cooperate with and show support for the aforementioned activities. Therefore, to effectively execute healthcare processes and standards, members of the team need to collaborate and communicate effectively with one another (American Diabetes Association, 2020).


To improve the standards for diabetes care at MMC, we need to use strategies that are not only ethical but also backed up by evidence. When it comes to improving the overall performance of healthcare practitioners in the provision of patient care, clinical decision-support technologies are very essential. Not only will the implementation of the fresh policies and regulations help the MMC achieve its goals, but they will also contribute to a reduction in the number of diabetic patients who need hospitalization as a result of their difficulties.


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NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

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