1. NHS-FP6004: Assessment 2: Policy Proposal – Online Nursing Essays
NHS-FP6004: Assessment 2: Policy ProposalNHS-FP6004: Assessment 2: Policy
ProposalWrite 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.IntroductionIn 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.RequirementsThe 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

2. 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?Click here to ORDER an A++ paper from our
Verified MASTERS and DOCTORATE WRITERS: NHS-FP6004: Assessment 2: Policy
ProposalHow 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 LengthIt 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.Supporting EvidenceCite 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.Competencies MeasuredBy
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

3. 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.NHS 6004 Policy
Proposal assessment 2Healthcare 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 CareAccording 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 ChangesFailure to address the established

4. 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
PerformancesIn 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
ComplianceMeeting 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 PointIn 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

5. the set objectives are followed and steps are taken towards reducing readmissions. The
teams will establish a standard process to use whenNHS 6004 Policy Proposal assessment
2documenting 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 2To 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
ResourcesAs 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
ConsiderationsTo 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 ImplementationAs 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

6. 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.ConclusionAn
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.