Student Name
Capella University
NHS-FPX 6004 Health Care Law and Policy
Prof. Name
Date
Policy Proposal
A healthcare organization functions in a constantly changing environment where variations in performance frequently occur. Monitoring performance indicators and addressing deficiencies is essential for maintaining high standards of patient care and ensuring patient safety. This document presents a policy proposal along with practice guidelines aimed at improving performance indicators previously identified at Mercy Medical Center (MMC). Earlier performance evaluations revealed a significant decline in two important diabetes management indicators: Hemoglobin A1c (HgbA1c) testing rates and annual diabetic foot examinations. Because these indicators are critical for effective diabetes management, targeted organizational policies and structured clinical guidelines are required to improve patient outcomes and strengthen the quality of care delivered at MMC.
Addressing Shortfalls: Creating Policy & Practice Guidelines
Healthcare quality benchmarks for diabetes management are established by recognized agencies such as the American Diabetes Association (ADA), the Centers for Medicare & Medicaid Services (CMS), and the National Healthcare Quality and Disparities Report (NHQDR) (ADA, 2019; CMS, 2023). These organizations recommend that individuals with diabetes undergo a Hemoglobin A1c test at least twice annually to monitor long-term blood glucose levels. Additionally, a comprehensive foot examination should be performed once each year to detect early signs of nerve damage, ulcers, or circulatory problems. These benchmarks support national public health objectives aimed at reducing diabetes-related complications and improving long-term patient health outcomes (ADA, 2019).
However, internal performance data from the MMC quality dashboard revealed that these benchmarks were not consistently achieved. The data indicated fluctuating performance across the four quarters of 2019 and 2020. Specifically, the HgbA1c testing rate declined from 78% in the third quarter of 2020 to 64% in the fourth quarter. Similarly, the rate of annual foot examinations also showed inconsistency, with a notable drop from 70% in the first quarter to 48% by the third quarter of 2020. These declining trends suggest an operational and clinical performance gap that requires corrective policy implementation and improved practice standards.
MMC Diabetes Care Benchmark Performance
| Indicator | Recommended Benchmark | MMC Performance Trend | Key Concern |
|---|---|---|---|
| HgbA1c Testing | At least twice annually | Declined from 78% (Q3 2020) to 64% (Q4 2020) | Reduced monitoring of blood glucose |
| Annual Foot Exam | Once per year | Dropped from 70% (Q1 2020) to 48% (Q3 2020) | Increased risk of foot complications |
The failure to meet these benchmarks can have serious clinical consequences for patients and organizational implications for MMC. When elevated HgbA1c levels go undetected, patients face a greater risk of developing serious complications such as neuropathy and nephropathy (Eyth & Naik, 2023). Persistent hyperglycemia can damage nerves, resulting in numbness, tingling sensations, and pain, while also impairing blood vessels that support cardiac health, thereby increasing the likelihood of stroke or heart attack. Kidney function can also deteriorate, reducing the organ’s ability to filter metabolic waste effectively.
Similarly, the absence of routine diabetic foot examinations increases the likelihood of undetected injuries, ulcers, and infections. Diabetes slows the healing process and heightens the risk of severe complications such as tissue damage or lower-limb amputation (Song & Chambers, 2021). Regular screening enables early identification of these problems and allows clinicians to intervene before complications progress.
Underperformance in these areas also affects the organization beyond clinical outcomes. Financially, treating diabetes complications significantly increases healthcare expenditures. Research indicates that approximately $1,096.21 per patient was spent on diabetes-related treatment between 2017 and 2020 (Birinci & Simten Malhan, 2023). Additionally, failure to comply with national quality standards may expose healthcare organizations to legal liabilities, regulatory penalties, and reputational damage within the community (Tomic et al., 2022). These factors collectively highlight the need for improved policy frameworks at MMC.
Existing literature further supports the necessity of consistent diabetes monitoring practices. For example, research emphasizes the role of routine foot assessments in preventing lower-limb complications among diabetic patients (Song & Chambers, 2021). Similarly, maintaining controlled HgbA1c levels has been linked to improved diabetes management and a reduction in long-term complications (Casadei et al., 2021). These findings reinforce the need for structured policy implementation and evidence-based clinical guidelines within MMC.
Proposed Organizational Policy and Practice Guidelines
To address the performance deficiencies identified at MMC, organizational policies should align with the benchmarks established by national healthcare authorities such as ADA, CMS, and NHQDR. These policies aim to improve diabetes management by ensuring consistent monitoring and preventive care.
Proposed Organizational Policies
| Policy Area | Policy Description | Expected Outcome |
|---|---|---|
| HgbA1c Monitoring | All diabetic patients must undergo HgbA1c testing at least twice annually in accordance with CMS standards. | Improved monitoring of blood glucose levels and reduced complication rates |
| Annual Foot Examination | Each diabetic patient must receive a comprehensive foot examination once every year following ADA clinical guidelines. | Early detection of neuropathy, ulcers, and circulation problems |
These policies reinforce standardized diabetes care protocols and contribute to improved health outcomes while ensuring compliance with national healthcare regulations (ADA, 2019; CMS, 2023).
Proposed Practice Guidelines
Effective policy implementation requires clear clinical guidelines that healthcare professionals can apply in everyday practice.
First, individualized diabetes management plans should be developed for each patient. Personalized care plans may include dietary adjustments, medication adherence strategies, and lifestyle recommendations tailored to individual patient needs. Such personalized approaches have been shown to enhance glycemic control and improve long-term patient outcomes (Sugandh et al., 2023).
Second, healthcare professionals must receive specialized training in performing comprehensive foot examinations and interpreting HgbA1c results. Training should include instruction on sensory testing, vascular assessment, and skin inspection techniques to detect early signs of complications. Educational programs can improve clinical competency and enhance the quality of diabetes care delivered by healthcare providers (Memon et al., 2021).
Third, patient education programs should be implemented to promote self-management practices. These programs should focus on lifestyle modifications such as maintaining healthy dietary habits, engaging in regular physical activity, and performing routine foot self-inspection. Educational materials—including brochures, visual guides, and informational pamphlets—can help patients understand the importance of regular testing and foot care practices (Ahmad & Joshi, 2023).
These policies and guidelines are designed for multiple stakeholders within the healthcare system. Healthcare providers are responsible for diagnosis and clinical care, administrators ensure resource allocation and policy implementation, and patients play an active role in self-management. Collaborative participation among these groups is essential for successful policy adoption.
Environmental Factors and Regulatory Considerations
The successful implementation of new policies and guidelines at MMC depends on several environmental and regulatory factors. Healthcare regulations are continuously updated to reflect changes in population health trends, demographics, and disease prevalence. Organizations must therefore remain aligned with evolving guidelines issued by agencies such as ADA, CMS, and NHQDR to avoid legal or ethical issues associated with non-compliance (ADA, 2019; CMS, 2023).
Staffing levels also play a crucial role in policy implementation. Insufficient staffing may lead to increased workloads, professional burnout, and higher risks of diagnostic or medication errors when conducting HgbA1c testing and foot assessments (Thorsen et al., 2020). Maintaining adequate staffing ensures that clinicians have sufficient time and resources to conduct comprehensive evaluations.
Financial considerations must also be addressed. Implementing these policies requires funding for staff recruitment, clinical training programs, patient education initiatives, and laboratory testing equipment. Without adequate financial planning, organizations may face difficulties sustaining quality improvement initiatives (Birinci & Simten Malhan, 2023).
To mitigate these challenges, administrative leadership should prioritize strategic resource allocation and operational planning. This includes establishing effective scheduling systems, improving patient record management, and allocating funding for staff training and recruitment. Additionally, implementing patient support systems—such as follow-up reminders and educational counseling—can strengthen long-term diabetes management and promote patient empowerment (Lowden, 2021).
Ethical, Evidence-Based Practice: Strategies from Literature
Evidence-based clinical practice strongly supports the routine monitoring of blood glucose levels and regular diabetic foot examinations. These practices enable early detection of complications and allow healthcare providers to intervene before irreversible damage occurs. The World Health Organization (WHO) highlights that early diagnosis and regular monitoring in primary care settings significantly reduce diabetes-related complications (WHO, 2023).
The proposed policies and practice guidelines are aligned with ethical principles and established clinical standards from CMS, ADA, and NHQDR. Training programs for healthcare professionals—including physicians, nurses, and allied health staff—ensure that clinical practices remain consistent with current medical evidence and regulatory requirements.
Patient-centered care is also central to ethical healthcare practice. Providing patients with individualized treatment plans and educational resources enables them to participate actively in their healthcare decisions. This approach supports ethical principles such as autonomy, beneficence, and nonmaleficence by ensuring that care decisions prioritize patient well-being and informed consent (Asadi et al., 2023).
Furthermore, training initiatives should consider the needs of diverse patient populations. Educational materials presented in simplified or multilingual formats can enhance understanding among patients from different cultural and linguistic backgrounds. Such inclusive strategies promote the ethical principle of justice by ensuring equitable access to healthcare information and services (Asadi et al., 2023).
Adhering to ethical and evidence-based standards will ultimately improve patient outcomes, strengthen MMC’s reputation in the healthcare community, and contribute to long-term organizational sustainability.
Stakeholder Involvement in Policy and Practice Guidelines
The success of healthcare policies often depends on the active participation of key stakeholders. At MMC, three major stakeholder groups play essential roles in implementing diabetes management policies: healthcare providers, healthcare administrators, and patients.
Healthcare providers—including physicians, nurses, and allied health professionals—are directly responsible for clinical diagnosis, testing procedures, and treatment planning. Nurses often assist with patient education, scheduling tests, and guiding patients through individualized diabetes management plans (Nurchis et al., 2022).
Healthcare administrators are responsible for operational planning and resource management. Their responsibilities include allocating financial resources, supporting staff recruitment and training initiatives, and ensuring that healthcare professionals have access to the tools required to perform regular HgbA1c testing and foot examinations (Seixas et al., 2021).
Patients themselves represent another critical stakeholder group. Their feedback and engagement in treatment decisions help healthcare providers evaluate the effectiveness of clinical practices and identify areas for improvement (Evans et al., 2023).
Stakeholder Roles in Policy Implementation
| Stakeholder | Key Responsibilities | Contribution to Policy Success |
|---|---|---|
| Healthcare Providers | Conduct tests, diagnose conditions, develop care plans | Improve clinical quality and patient outcomes |
| Administrators | Manage resources, implement policies, support staff training | Ensure operational efficiency and compliance |
| Patients | Participate in treatment decisions and provide feedback | Enhance patient-centered care |
Active collaboration among these stakeholders encourages shared accountability and strengthens adherence to policy standards. Stakeholder engagement also facilitates effective decision-making, improves resource distribution, and fosters a positive healthcare environment that supports quality improvement initiatives (Racine et al., 2023).
Conclusion
In summary, implementing evidence-based policies and structured clinical guidelines at Mercy Medical Center is essential for improving diabetes management and addressing current performance gaps. The declining rates of HgbA1c testing and annual foot examinations highlight the need for organizational intervention. By aligning with national standards established by ADA, CMS, and NHQDR, MMC can strengthen its clinical practices and improve patient health outcomes.
The proposed policies emphasize regular HgbA1c testing twice annually and annual diabetic foot examinations, supported by staff training, patient education programs, and personalized treatment plans. Addressing environmental factors, ethical considerations, and stakeholder collaboration will further enhance the effectiveness of these initiatives. Ultimately, these policy improvements will contribute to higher quality care, reduced diabetes complications, and improved organizational performance at MMC.
References
ADA. (2019). Standards of medical care in diabetes—2019 abridged for primary care providers. Clinical Diabetes, 37(1), 11–34. https://doi.org/10.2337/cd18-0105
Ahmad, F. J., & Joshi, S. H. (2023). Self-care practices and their role in the control of diabetes: A narrative review. Cureus, 15(7). https://doi.org/10.7759/cureus.41409
Asadi, M., Zahedi, F., Ebrahimpur, M., & Larijani, B. (2023). Ethical challenges in gestational diabetes. Journal of Medical Ethics and History of Medicine. https://doi.org/10.18502/jmehm.v16i6.13470
Birinci, S., & Simten Malhan, B. (2023). Distribution and economic burden of diabetes-related microvascular complications in Türkiye. Anatolian Journal of Cardiology, 27(10), 597–607. https://doi.org/10.14744/AnatolJCardiol.2023.3762
Casadei, G., Filippini, M., & Brognara, L. (2021). Glycated hemoglobin (HbA1c) as a biomarker for diabetic foot peripheral neuropathy. Diseases, 9(1), 16. https://doi.org/10.3390/diseases9010016
CMS. (2023). Medicare Diabetes Prevention Program (MDPP) expanded model. https://www.cms.gov/priorities/innovation/innovation-models/Medicare-diabetes-prevention-program
NHS FPX 6004 Assessment 2 Policy Proposal
Evans, K., Williams, A. G., Pearson, M., Kotera, Y., & Enston, C. (2023). Health service improvement using positive patient feedback: Systematic scoping review. PLOS ONE. https://doi.org/10.1371/journal.pone.0275045
Eyth, E., & Naik, R. (2023). Hemoglobin A1C. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549816/
Lowden, A. R. P. (2021). Clinical decision support for diabetes care in the hospital. Journal of Diabetes Science and Technology. https://doi.org/10.1177/1932296820982661
Memon, R., Levitt, D., Salgado Nunez Del Prado, S. R., Munir, K., & Lamos, E. (2021). Knowledge of hemoglobin A1c and glycemic control in an urban population. Cureus, 13(3), e13995. https://doi.org/10.7759/cureus.13995
Nurchis, M. C., Sessa, G., Pascucci, D., Sassano, M., Lombi, L., & Damiani, G. (2022). Interprofessional collaboration and diabetes management in primary care. Journal of Personalized Medicine, 12(4), 643. https://doi.org/10.3390/jpm12040643
Racine, E., O Mahony, L., Riordan, F., Flynn, G., Kearney, P. M., & McHugh, S. M. (2023). What and how do different stakeholders contribute to intervention development? HRB Open Research, 5, 35. https://doi.org/10.12688/hrbopenres.13544.2
Seixas, B. V., Dionne, F., & Mitton, C. (2021). Practices of decision making in priority setting and resource allocation. Health Economics Review, 11(1). https://doi.org/10.1186/s13561-020-00300-0
NHS FPX 6004 Assessment 2 Policy Proposal
Song, K., & Chambers, A. R. (2021). Diabetic foot care. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553110/
Sugandh, F. N. U., et al. (2023). Advances in the management of diabetes mellitus: A focus on personalized medicine. Cureus, 15(8). https://doi.org/10.7759/cureus.43697
Thorsen, M., McGarvey, R., & Thorsen, A. (2020). Diabetes management at community health centers. Social Science & Medicine, 255, 113017. https://doi.org/10.1016/j.socscimed.2020.113017
Tomic, D., Shaw, J. E., & Magliano, D. J. (2022). The burden and risks of emerging complications of diabetes mellitus. Nature Reviews Endocrinology, 18(9), 525–539. https://doi.org/10.1038/s41574-022-00690-7
WHO. (2023). Diabetes. https://www.who.int/health-topics/diabetes