NHS 6004 Policy Proposal 2nd assessment
Policies and procedures in the healthcare industry are critical because they ensure that a company follows accepted professional standards (Waters et al., 2015). They also ensure that a company complies with all applicable laws, rules, and accreditation requirements. To guarantee that the organization fulfills the specified criteria at the local, state, and national levels, policies and practices should be evaluated and modified on a regular basis. The major goal of this study is to recommend a change in organizational policy and practice to address the underperformances discovered by an analysis of the Health Point Clinical Safety Dashboard. The paper will discuss underperformance ratings, how they affect the quality of treatment, the consequences of not making adjustments, and ethical, evidence-based ways for dealing with the problem.
Health Point’s performance on the Clinical Safety Dashboard was found to be lacking in three areas. Because the hospital readmission rates were higher than the 17 percent threshold for Medical Care readmission, they were considered high. The issue arose from the discharge process, which took place between the hours of 8 a.m. and 12:59 p.m. The hospital’s fall rate was likewise high, exceeding the stipulated standard of 11.5 per 1000 patient days. The hospital’s goal was to cut fall rates by 70%, but they only managed to achieve a 50% reduction since they did not follow the Fall Injury Reduction Protocol Policy’s guidelines. The hospital’s performance on hospital-acquired infections was also unsatisfactory, since it was 20%, which was more than the state’s projected threshold of 10%.
How Does Underperformance Affect Care Quality?
Hospitals should ensure that the number of unnecessary 30-day readmissions is reduced, according to the Hospital Readmissions Reduction Program (HRRP). Increased readmissions are associated with underperforming hospitals, and they cause inconvenience for patients as well as a financial cost for the hospital. When compared to first admissions, readmission lengthens the stay and increases the likelihood of complications, both of which should be avoided due to the related expenses (Moore et al., 2017). According to research, the most common reasons of unexpected readmissions are postoperative complications and patient safety events, both of which are caused by poor-quality treatment (McIlvennan, Eapen, & Allen, 2015). Increased fall rates are also associated to poor care quality because they result in long-term pain, disability, early admissions, longer hospital stays, functional impairment, and mortality (Simon, Maben, Murrells, & Griffiths, 2016). Falling rates raise not just staff burden, but also hospital costs, which should be avoided. Hospital-acquired infections (HAI) have a negative impact on care because they lengthen hospital stays, raise antibiotic resistance, cause long-term disability, result in unnecessary deaths, and cost the health system, patients, and their families more money.
Consequences of Failure to Change
Failure to address the hospital’s existing shortcomings will have an impact on its operations. For example, patient satisfaction will drop, and the hospital’s reputation will suffer, ultimately impacting hospital revenues. Staff shortages, increasing workloads, and poor care quality will all result from higher turnover rates. Health Point’s operating costs will rise as a result of higher readmission rates, and it will exceed risk-adjusted readmission rates, resulting in a loss of up to 3% of CMS payments (Waters et al., 2015). Readmission rates are associated to a 4.6-day increase in hospital stay, which increases the cost of care by $5800. Second, as a result of an increase in patient falls, CMS will no longer reimburse Health Point since falls are deemed a near-event. The Centers for Medicare and Medicaid Services (CMS) does not reimburse hospitals for costs associated with patient falls. Finally, Medicare pays hospitals based on their performance, and low scores in hospital-acquired infections put them in the bottom quartile. As a result, the hospital will lose 1% of its Medicare revenue (Waters et al., 2015).
Efforts to Improve Performance Using Evidence-Based Strategies
Evidence-based research reveals that hospitals must improve the effectiveness of their care transition by resolving communication breakdown, improving patient education, and increasing clinician responsibility in order to prevent hospital readmissions (McHugh et al., 2017). Other readmission-prevention measures include assigning nurses to manage medication schedules, developing a post-discharge plan, scheduling follow-up appointments for patients right before discharge, and following up with test findings after discharge. The use of call lights has been demonstrated to lessen falls when it comes to preventing them. Other techniques include hourly rounding, which helps anticipate patient requirements and analyzing environmental dangers that can contribute to patient falls (Callis, 2016). A “no-pass zone” in the hospital might also be reinforced to aid in speedy responses to patient requirements. Hand hygiene is the single most effective technique for preventing hospital-acquired illnesses, and it requires everyone to do it effectively (McCalla, Reilly, Thomas & McSpedon-Rai, 2017).
How Do EBP Strategies Make It Easier to Comply?
Meeting the established benchmarks necessitates the use of tried-and-true methods. The evidence-based solutions outlined above should assist Health Point in meeting local, state, and national goals. Making transition care more effective, for example, will guarantee that patient education materials are standardized and that patients are not overwhelmed by lengthy discharge instructions, thus reducing drug mismanagement. Patients will be able to take the required steps to recover and prevent the need for extra healthcare treatments if hospital follow-up appointments are consistently scheduled (McHugh et al., 2017). In terms of patient falls, hourly rounding ensures that patients’ toileting needs are met, personal possessions are within reach, pain assessments are completed, and repositioning is carried out as planned. Furthermore, using a “no pass zone” assures that all employees can answer call lights as they walk down the hall. Hand hygiene, on the other hand, minimizes pathogen acquisition and, as a result, reduces HAI rates in hospitals.
Adoption of Health Point Strategies
Readmission rates will be managed in Health Point using a policy known as CARE (Controlling Avoidable Readmissions Effectively). A physician champion will lead a collaborative effort that includes nurse leaders, patient care facilitators, social workers, case managers, and physicians. The policy will call for a monthly meeting to ensure that the goals are met and that steps are being taken to reduce readmissions. The teams will develop a common procedure to follow while they are working togethe
Keeping track of a patient’s comorbid conditions and complexity in order to improve clinical documentation accuracy and communicate medical needs (McHugh et al., 2017). To manage care transition, the hospital will create standardized tools to identify high-risk patients, educate patients about their disease conditions as well as potential medication side effects, schedule follow-up appointments, reconcile medication, and ensure that the drugs prescribed during their discharge interact well with the ones prescribed previously. The hospital will employ call lights to minimize fall rates, and the policy will include training to help nurses understand how to respond to call light signals as well as tactics to apply when teaching their patients to use call lights. Hand hygiene policies will be implemented for hospital-acquired infections, requiring all workers providing direct or indirect care to wash hands before handling patients. Other situations that necessitate hand cleaning will be discussed, such as after removing gloves and aiding patients.
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The new plans will be prepared and distributed to all staff to ensure that they are ethical and culturally inclusive. To improve their comprehension, all concerned staff would be trained and guided through the strategies. Prior to implementation, all employees’ opinion will be sought to ensure that it is incorporated into the new policies and that they understand the main concept behind their creation. The reason for integrating all personnel is that every project necessitates a concentrated, coordinated effort from everyone in the facility. The new principles promote an inclusive culture by providing caregivers and patients with relationship-centered care that is focused on health and wellness.
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Organizational Resources and Environmental Factors
As previously stated, Health Point is extending its business throughout the state, which could obstruct the implementation of the initiatives. The expansion will lower the number of resources required to carry out each phase of the instructions. According to research, a shortage of resources has an impact on the quality of medical services (Supper et al., 2015). With fewer resources, there is a risk of personnel shortages, fragmented treatment, and a lack of time to meet the requirements of individual patients. Support services may be lacking in policy implementations, making them ineffective. Finances can also be a problem, particularly when it comes to training and empowering all of the company’s employees.
Regulations to Think About
It is necessary to obtain a license and a certificate from the Maryland Office of Health Care Quality (OHCQ) in order to apply the new policies. OHCQ sets basic standards of care using state and federal rules and performs surveys to ensure compliance (Edrees, Morlock & Wu, 2017). Despite the fact that the proposed measures are targeted at improving state, municipal, and national benchmarks on readmissions, HAI, and falls, an OHCQ certificate is required.
As previously said, everyone in the hospital will be involved in the implementation. Nonetheless, the CARE policy will be championed by a physician who will collaborate with nurse leaders, patient care facilitators, social workers, case managers, and physicians to ensure that the policies fulfill their goals. The project will be led by the team to guarantee that it accomplishes its goals. Nurses are the policy’s main counterpart when it comes to call lights. They will be taught on how to respond to signals as well as how to educate patients on how to use the signals, as previously said. As a result, the call light’s deployment will be smooth, as a “no pass zone” will be established to help avoid falls. The hospital’s entire personnel will be included in the hand hygiene program. Aside from hand hygiene training, posters displaying the processes will be put in various patient care points to alert everyone and guarantee that they follow the rules.
Health Point did not achieve local, state, or national goals for readmissions, falls, or hospital-acquired infections, according to the Clinical Safety Dashboard. Evidence-based techniques were included into policies and procedures to assist in meeting these goals. A CARE policy was proposed to combat readmissions, while call lights were used to resolve fall rates. Finally, hand hygiene has been suggested as a way to combat hospital-acquired diseases. Because the hospital is growing, the implementation may confront resource constraints; however, management must evaluate the benchmarks and guarantee that the hospital does not face the consequences stated in the paper.
Write a 4-6-page policy proposal and practice guidelines for improving quality and performance associated with the benchmark metric underperformance you advocated for improving in Assessment 1.
In advocating for institutional policy changes related to local, state, or federal health care laws or policies, health leaders must be able to develop and present clear and well-written policy and practice guideline proposals that will enable a team, a unit, or an organization as a whole to resolve relevant performance issues and bring about improvements in the quality and safety of health care. This assessment offers you an opportunity to take the lead in proposing such changes.
As a master\’s-level health care practitioner, you have a valuable viewpoint and voice to bring to discussions about policy development, both inside and outside your care setting. Developing policy for internal purposes can be a valuable process toward quality and safety improvement, as well as ensuring compliance with various health care regulatory pressures. This assessment offers you an opportunity to take the lead in proposing such changes.
Propose organizational policy and practice guidelines that you believe will lead to an improvement in quality and performance associated with the benchmark underperformance you advocated for improving in Assessment 1. Be precise, professional, and persuasive in demonstrating the merit of your proposed actions.
Note: Remember that you can submit all, or a portion of, your draft policy proposal to Smarthinking for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.
The policy proposal requirements outlined below correspond to the scoring guide criteria, so be sure to address each main point. Read the performance-level descriptions for each criterion to see how your work will be assessed. In addition, be sure to note the requirements for document format and length and for supporting evidence.
Explain the need for creating a policy and practice guidelines to address a shortfall in meeting a benchmark metric prescribed by local, state, or federal health care policies or laws.
What is the current benchmark for the organization and the numeric score for the underperformance?
How is the benchmark underperformance potentially affecting the provision of quality care or the operations of the organization?
What are the potential repercussions of not making any changes?
What evidence supports your conclusions?
Recommend ethical, evidence-based practice guidelines to improve targeted benchmark performance prescribed by applicable local, state, or federal health care policy or law.
What does the evidence-based literature suggest are potential strategies to improve performance for your targeted benchmark?
How would these strategies ensure performance improvement or compliance with applicable local, state, or federal health care policy or law?
How would you propose to apply these strategies in the context of Eagle Creek Hospital or your own practice setting?
How can you ensure these strategies are ethical and culturally inclusive in their application?
Analyze the potential effects of environmental factors on your recommended practice guidelines.
What regulatory considerations could affect your recommended guidelines?
What resources could affect your recommended guidelines (staffing, financial, and logistical considerations, or support services)?
Explain why particular stakeholders and groups must be involved in further development and implementation of your proposed policy and practice guidelines.
Why is it important to engage these stakeholders and groups?
How can their participation produce a stronger policy and facilitate its implementation?
Organize content so ideas flow logically with smooth transitions.
Proofread your proposal, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your proposal.
Use paraphrasing and summarization to represent ideas from external sources.
Be sure to apply correct APA formatting to source citations and references.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:
Assessment 2 Example [PDF].
Policy Proposal Format and Length
It may be helpful to use a template or format for your proposal that is used in your current organization. The risk management or quality department could be a good resource for finding an appropriate template or format. If you are not currently in practice, or your organization does not have these resources, many appropriate templates are freely available on the Internet.
Your policy should be succinct (about one paragraph). Overall, your proposal should be 4–6 pages in length.
Cite 3–5 references to relevant research, case studies, or best practices to support your analysis and recommendations.
Note: Faculty may use the Writing Feedback Tool when grading this assessment. The Writing Feedback Tool is designed to provide you with guidance and resources to develop your writing based on five core skills. You will find writing feedback in the Scoring Guide for the assessment, once your work has been evaluated.
Portfolio Prompt: You may choose to save your policy proposal to your ePortfolio.
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
Competency 1: Analyze relevant health care laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
Analyze the potential effects of environmental factors on recommended practice guidelines.
Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
Recommend ethical, evidence-based practice guidelines to improve targeted benchmark performance prescribed by applicable local, state, or federal health care policies or laws.
Competency 3: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, to inform health care laws and policies for patients, organizations, and populations.
Explain the need for creating a policy to address a shortfall in meeting a benchmark metric prescribed by local, state, or federal health care policies or laws.
Competency 4: Develop strategies to work collaboratively with policy makers, stakeholders, and colleagues to address environmental (governmental and regulatory) forces.
Explain why particular stakeholders and groups must be involved in further development and implementation of a proposed policy and practice guidelines.
Competency 5: Produce clear, coherent, and professional written work, in accordance with Capella\’s writing standards.
Organize content so ideas flow logically with smooth transitions.
Use paraphrasing and summarization to represent ideas from external sources.