NHS 6004 Policy Proposal assessment 2

NHS 6004 Policy Proposal assessment 2

NHS 6004 Policy Proposal assessment 2

I recently learned about nurse that didn’t follow the standards of professional accountability when it came to medication administration and the out come resulted in death of the patient and much pain and suffering for that family after the loss of their family member. The nurse should have followed her 5 rights to medication administration. Right patient, right medication, right dose, right route, right time. In this instance this nurse overrode the pyxis and pulled vecuronium when she was supposed to pull versed. This mistake could have been prevented if the nurse followed the standards of professional accountability when it comes to patient safety and medication administration safety checks. Nurses are given great responsibility when it comes to caring for the lives of others, the accountability that the general public places in nurses is so great that nurses must always follow the standard of professional accountability in their day to day work in order to create a safe practice that becomes their second nature. Yes, the system that is in place could often times fail a nurse resulting in a sentinel event although, as a licensed nurse it is imperative to fall back on always using safe patient standards no matter where you work in order to protect patient safety and the RN license.

Healthcare policies and procedures are essential because they ensure that an organization adheres to recognized professional practices (Waters et al., 2015). They also make an organization compliant with regulations statutes and accreditation requirement. The policies should be reviewed regularly and practices updated to ensure that the organization meets the set benchmarks at the local, state and national level. The primary purpose of the present paper is to propose a change in organizational policy and practice to handle the underperformances observed after analyzing the Health Point Clinical Safety Dashboard. The paper will outline the underperformance scores, how they affect the quality of care, repercussion of not making changes and ethical, evidence-based strategies to handle the performance issue.

The evaluation of the Clinical Safety Dashboard indicated that Health Point performance is wanting in three areas. The hospital readmission rates were high because it was above the 17% set for Medical Care readmission. The problem stemmed from the discharge protocol which happened between 8.00 am and 12.59 pm. The hospital also had a high fall rate since it exceeded the set standard of 11.5 per 1000 patient days. The hospital plan was to reduce the fall rates by 70%however they only achieved a 50% reduction because they did not follow the recommendations stipulated in the Fall Injury Reduction Protocol Policy. The hospital performance on hospital-acquired infections was also poor since it was 20% which was above the expected state benchmark of 10%.

How Underperformance Affects the Quality of Care

According to the Hospital Readmissions Reduction Program (HRRP), hospitals should ensure that they reduce the number of preventable 30-day readmissions. Increased readmissions are linked to poor-performing hospitals and they result in inconveniences for the patients and becomes a burden to the hospital. Readmission increases length of stay compared to first admissions as well as risk of complications which should be avoided due to the associated costs (Moore et al., 2017). Research indicates that postoperative complications and patient safety events are the major causes of unplanned readmissions and they result from poor –quality care (McIlvennan, Eapen, & Allen, 2015).  Increased fall rates also are linked to poor quality of care because they result in longstanding pain, disability, premature admissions, prolonged length of stay in hospital, functional impairment, as well as mortality (Simon, Maben, Murrells, & Griffiths, 2016). Fall rates not only increase staff workload but also increase hospital cost which should be reduced. Hospital-acquired infections (HAI) also affects care because they increase hospital stay, increase resistance to antimicrobials, long-term disability, lead to unnecessary deaths, increase cost to the health system, patients and their families.

Repercussions of not Making Changes

Failure to address the established weaknesses in the hospital will affect its operations. For instance, patient satisfaction levels will reduce and the reputation of the hospital will be low impacting the hospital finances negatively. The turnover rates will also increase, leading to staff shortage, increased workload and poor quality of care. To be specific, due to increased readmissions rates, Health Point will increase its operation cost and it will surpass the risk-adjusted readmission rates resulting in loss of up to 3% of CMS payments (Waters et al., 2015). Readmissions rates are linked to increased hospital stay by 4.6 days which heightens the cost of care by $5800. Secondly, increased patient falls means that CMS will stop reimbursing Health Point since falls are considered as near event. Center for Medicare and Medicaid Services does not reimburse hospital for the additional cost linked to patient falls. Lastly, Medicare uses payment for performance and poor scores in hospital-acquired infections place a hospital in the bottom quartile. The result is that the hospital loses 1% of its Medicare revenue (Waters et al., 2015).

Evidence-Based Strategies to Improve Performances

In order to reduce hospital readmissions, evidence-based research indicates that hospitals have to enhance the effectiveness of their care transition by addressing communication breakdown, enhancing patient education as well as clinician accountability (McHugh et al., 2017). Other strategies that address readmission include apportioning nurses to oversee medication plans, coming up with a post-discharge plan, scheduling follow-up appointment for the patients immediately before discharge and following up patients after discharge with test results. In preventing falls, the use of call lights has been shown to reduce falls. Other measures include hourly rounding which assists in anticipating patient needs as well as assessing environmental hazards, which can contribute to patient falls (Callis, 2016). One can also reinforce a “no-pass zone” in the hospital to help in quick responses to patient needs.  For hospital-acquired infections, the single most effective strategy is hand hygiene which stipulates that everyone has to perform hand hygiene properly (McCalla, Reilly, Thomas & McSpedon-Rai, 2017).

How the EBP Strategies Enhance Compliance

Meeting the set benchmarks requires measures that have been proven to work. The evidence-based strategies above are expected to help Health Point achieve the local, state and national benchmarks. For instance, making transition care effective will ensure that patient education materials are standardized and patients do not get overwhelmed due to complex discharge instructions reducing medication mismanagement.  Scheduling of hospital follow-up appointment will also be consistently enabling the patients to execute necessary steps to recover and avoid the need for additional healthcare interventions (McHugh et al., 2017). In terms of patient falls, hourly rounding ensures that patient toileting needs are addressed, personal belongings are within the reach of patients, pain assessment is executed and reposition occurs as expected. Additionally, the use of “no pass zone” ensures that all employees can answer call lights when they go down the hallway. Hand hygiene, on the other hand, reduces the acquisition of pathogens which ultimately reduce the rates of HAI in the hospital.

Adopting the Strategies at Health Point

In Health Point, readmission rates will be handled through a policy dubbed as CARE (Controlling Avoidable Readmissions Effectively). It will be a collaborative approach with a physician champion working together with nurse leaders, patient care facilitators, social workers, case managers, and physicians. The policy will propose a monthly meeting to ensure that the set objectives are followed and steps are taken towards reducing readmissions. The teams will establish a standard process to use when

NHS 6004 Policy Proposal assessment 2
NHS 6004 Policy Proposal assessment 2

documenting patient comorbid diagnoses and complexity with the aim of enhancing clinical documentation accuracy and communicating patient medical needs (McHugh et al., 2017). To manage care transition, the hospital will develop standardized tools to establish high-risk patients, educate patients regarding their disease conditions as well as possible medication side effects, plan follow-up appointments, reconcile medication and ensure that the drugs prescribed during their discharge interact well with the ones that were previously prescribed. To reduce fall rates, the hospital will adopt call lights and in the policy, training will be offered to help nurses learn to respond to call light signals as well as empower them with strategies to use when training their patients to use call lights. For hospital-acquired infection, a policy on hand hygiene will be developed requiring all personnel providing direct or indirect care to wash hands before handling patients. Other instances requiring hand washing will also be outlined such as after removing gloves and after assisting patients.

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NHS 6004 Policy Proposal assessment 2

To ensure that the new strategies are ethical and culture inclusive, they will be written and distributed to all employees. All concerned employees will also be trained and taken through the strategies to enhance their understanding. Equally, prior to implementation, the input of all staff will be taken to insure that it is incorporated in the new policies and they understand the basic idea behind their development. The reason for involving all the employees is that any initiative requires focused, concerted effort from everyone within the hospital. The new policies foster inclusive culture because they offer relationship-centered care for the caregivers and patients centered on health and wellness.

Environmental Factors and Organizational Resources

As outlined earlier, Health Point is expanding its business across the state which may hinder the implementation of the specified strategies. The expansion will reduce the available resources needed to execute each and every step of the guidelines. Research indicates that quality of medical services is affected by lack of resources (Supper et al., 2015). With limited resources there is a risk of staff shortage, fragmented care as well as limited time to cater to individual patient needs. The policy implementations may lack support services needed to make them effective. Finances may also be a challenge especially when it comes to training and empowering all the staff in the organization.

Regulatory Considerations

To implement the new policies, there is a need to get a license and a certificate from the Office of Health Care Quality (OHCQ) Maryland. OHCQ uses state and federal regulations to set minimum standards of care and conducts surveys to establish compliance (Edrees, Morlock & Wu, 2017). Although the proposed policies are aimed at enhancing the state, local and national benchmarks on readmissions, HAI and falls, there is a need to get a certificate from OHCQ.

Stakeholders in Implementation

As outlined above the implementation will involve everyone in the hospital. Nevertheless, to ensure that the policies achieve their intended purposes the CARE policy will be championed by a physician who will work hand in hand with nurse leaders, patient care facilitators, social workers, case managers, and physicians. The team will spearhead the project to ensure that it achieves its set purpose. For the call lights, the nurses are the major counterpart in the policy. As indicated they will be trained on how to respond to signals as well as on educating the patients on how to use the signals. The implementation of the call light will, therefore, be seamless since a “no pass zone” will be set to help in preventing falls. The hand hygiene will incorporate all the staff within the hospital. Apart from training on hand hygiene, posters indicating the procedures will be placed in various patients care point to sensitive everyone and ensure that they are compliant with the set measures.


An analysis of the Clinical Safety Dashboard revealed that Health Point did not meet local, state and national benchmarks on readmissions rates, fall rates, and hospital-acquired infections. To help meet these benchmarks, evidence-based strategies were developed into policies and procedures. To combat readmissions a CARE policy was proposed while fall rates were resolved using call lights. Lastly, hand hygiene was proposed as a measure to deal with hospital-acquired infections. The implementation may face resource challenges since the hospital is expanding its business however, the management has to consider the benchmarks and ensure that it does not face the repercussions outlined on the document.

This assignment builds on the Previous Assessment 1 Order # 13045 so the policy proposal will follow the Dashboard and Benchmark Evaluation ; If possible I would like to include POCT (Point of Care Testing) in the policy proposal to provide efficient and accurate bedside, ED, and surgical dept laboratory test results that would help better patient outcomes. Training could incorporate an interdisciplinary team to include the laboratory.
Here are the course instructions:

Proposal Requirements
Note: The tasks outlined below correspond to grading criteria in the scoring guide.
In your proposal, senior leaders have asked that you:
Explain why a change in organizational policy or practice guidelines is needed to address a shortfall in meeting a performance benchmark prescribed by applicable local, state, or federal health care laws or policies.
What is the current benchmark for the organization? What is the numeric score for the underperformance?
How might the benchmark underperformance be affecting the quality of care being provided or the operations of the organization?
What are the potential repercussions of not making any changes?
Recommend ethical, evidence-based strategies to resolve the performance issue.
What does the evidence-based literature suggest are potential strategies to improve performance for your targeted benchmark?
How would these strategies ensure improved performance or compliance with applicable local, state, or federal health care laws or policies?
How would you propose to apply these strategies in the context of your chosen professional practice setting?
How would you ensure that the application of these strategies is ethical and culturally inclusive?
Does your policy encompass the key components of your recommendations?
Analyze the potential effects of environmental factors on your recommended strategies.
What regulatory considerations could affect your recommended strategies?
What organizational resources could affect your recommended strategies (for example, staffing, finances, logistics, and support services)?
Are your policy and guidelines realistic in light of existing environmental factors?
Propose a succinct policy and guidelines to enable a team, unit, or the organization as a whole to implement recommended strategies to resolve the performance issue related to the relevant local, state, or federal health care policy or law.
Identify colleagues, individual stakeholders, or stakeholder groups who should be involved in further development and implementation of your proposed policy, guidelines, and recommended strategies.
Why is it important to engage these colleagues, individual stakeholders, or stakeholder groups?
Do your proposed guidelines help colleagues, individual stakeholders, or stakeholder groups understand how to implement your proposed policy?
How might engaging these colleagues, individual stakeholders, or stakeholder groups result in a better organizational policy and smoother implementation?
Are your proposal and recommended strategies realistic, given the care team, unit, or organization you are considering?
Communicate your proposed policy, guidelines, and recommended strategies in a professional and persuasive manner.
Write clearly and logically, using correct grammar, punctuation, and mechanics.
Integrate relevant sources to support your arguments, correctly formatting source citations and references using current APA style.
Did you cite an additional 3–5 credible sources to support your analysis and recommendations?

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: NHS 6004 Policy Proposal assessment 2