session

This activity asks you to review a diabetes dashboard and fact sheet used by Mercy Medical Center, a Vila Health affiliated hospital, and determine where the organization is falling short. Public Health Dashboard - Diabetes Eye Exam Foot Exam

Mercy Medical Center (Shakopee, MN)

Mercy Medical Center is one of the region's top choices for high quality health care. Don't just take our word for it, though. Here are some of the accolades we've received:

· Highest Safe Surgery Rating by a consumer advocacy magazine.

· Healthgrades Outstanding Patient Experience Award.

· Shakopee Ledger Top 20 Workplaces 2020 and 2021.

· Women's Choice Award for the Best Hospital for Patient Experience in Emergency Care. Shakopee Demographics Male – 25% Female – 25% Total population – 50% Age Group Yellow – 34 % Blue – 42% Grey – 17% Red – 7% Race White – 57% Asian – 8% Hispanic-Latino – 6%. African-American – 3%. Two Races – 2% American-Indian – 1% Other – 23% Shakopee Ledger—Top Workplaces 2020 & 2021 2010 Hospital Rooms (all private) – 42% Medical/Surgical Rooms – 22% Special Care Unit – 5% Family Birth Rooms – 12% Children’s Care Pediatric Rooms – 3% Operating Rooms – 3% Emergency Room Treatment Bays – 11% Endoscopy Room – 1% 2021 Hospital Rooms (all private) – 42% Medical/Surgical Rooms – 28% Special Care Unit – 4% Family Birth Rooms – 8% Children’s Care Pediatric Rooms – 2% Operating Rooms – 4% Emergency Room Treatment Bays – 10% Endoscopy Room – 1% 2021 Physicians – 0% Volunteers – 0% Inpatient Admissions – 2% Surgical Procedures – 2% Births – 0% Emergency Room – 10% Urgent Care Visits – 3% Outpatient Encounters – 39% Physical, Occupational, Speech/Language Therapy Visits – 9% Pediatric Therapy Visits – 4% Sleep Center Visits – 0% Radiology Procedures – 19% Cardiac Rehab Visits – 2% Cardiopulmonary Visits – 6% Cancer Center Visits – 3%

Use the resources linked below to help complete this assessment.

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Protecting Patient Privacy

Refer to the following reading list:

· Assessment 3: Protecting Patient Privacy .

Health Care Regulatory Agencies

The following reading list will further your understanding of the major health care regulatory agencies. They include the Joint Commission, CMS, and HHS. Compare the similarities and differences between these three major agencies that directly correlate with regulatory mandates, reimbursement, and accreditation of organizations. Leaders must understand the various requirements for which health care organizations are accountable.

· Assessment 3: Health Care Regulatory Agencies .

Quality Improvement

Ongoing quality and performance improvement in health care is crucial for sustainability. As technology improvements lead to better outcomes, consumer expectations rise. Health literacy has created an informed customer, and the patient experience is a measurement directly related to reimbursement for hospitals and health care organizations.

Performance improvement strategies that have been applicable in manufacturing and automotive industries are now commonplace in health care. Leaders must understand their critical role in continuous improvement in their organizations.

Refer to the following reading list to gain a better understanding of performance improvement strategies:

· Assessment 3: Quality Improvement .

Review your Assessment 3 Training Session Best Practices activity, which provides an opportunity for you to check your knowledge of training best practices, before you begin the assessment.

Ethics

Establishing good ethical standards in health care organizations and facilities is mandatory to meet compliance with federal and state standards in the treatment of patients and for facility operations.

Refer to the following reading list:

· Assessment 3: Ethics .

Policy Statements

Refer to the following reading list:

· Assessment 3: Policy Statements .

Design a training session presentation (8-12 slides) for one of the role groups in the organization that will be responsible for implementation.

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Introduction

Training and educating those within an organization who are responsible for implementing and working with changes in organizational policy is a critical step in ensuring that prescribed changes have their intended benefit. A leader in a health care profession must be able to apply effective leadership, management, and educational strategies to ensure that colleagues and subordinates will be prepared to do the work that is asked of them.

As a master's-level health care practitioner, you may be asked to design training sessions to help ensure the smooth implementation of any number of initiatives in your health care setting. The ability to create an agenda that will ensure your training goals will be met, and will fit into the allotted time, is a valuable skill for preparing colleagues to be successful in their practice.

This assessment offers you an opportunity to develop and implement effective educational strategies.

Instructions

To help ensure a smooth rollout and implementation of your proposed policy and practice guidelines, design a training session presentation for one of the role groups in the organization that will be responsible for implementation.

· Provide a brief summary of your strategies for working with your chosen role group.

· Explain the impact of the new policy on the group and the importance of the change to improve quality of care.

· Explain how the group is important in implementing your proposed policy and practice guidelines and why you chose this group to pilot your proposal.

· Determine appropriate instructional content and explain to the group the learning activities and materials they should expect during the training session.

· Prepare an annotated agenda for a two-hour training session.

During this training session, you will want to ensure that the individuals you are training understand the new policy and practice guidelines. You will need them to buy into the importance of the policy in improving the quality of care or outcomes and their key role in successful policy implementation. You must help them acquire the knowledge and skills they need to be successful in implementing the policy and practice guidelines.

As outcomes of this training session, participants are expected to:

· Understand the organizational policy and practice guidelines to be implemented.

· Understand the importance of the policy to improving quality or outcomes.

· Understand that, as a group, they are key to successful implementation.

· Possess the necessary knowledge and skills for successful implementation.

 

Requirements

The strategy summary and annotated training agenda 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.

· Summarize evidence-based strategies for working with the role group to obtain their buy-in and prepare them to implement the new policy and apply the associated practice guidelines to their work.

· Why will these strategies be effective?

· What measures might provide early indications of success?

· Explain the impact of the new policy and practice guidelines.

· How they will be implemented?

· How will they affect the daily work routines and responsibilities of the role group?

· Justify the importance of the new policy and practice guidelines with regard to improving the quality of care or outcomes related to the role group's work.

· How will the policy and guidelines help improve the quality of care or outcomes?

· Explain the role group's importance in implementing the new policy and practice guidelines.

· Why is the work and buy-in of the role group important for successful implementation?

· How could you help the group feel empowered by their involvement during implementation?

· Determine appropriate and effective instructional content, learning activities, and materials for the training session.

· How will each proposed activity on your agenda support learning and skill development?

· Can you complete the training within the allotted two hours?

· Deliver a persuasive, coherent, and effective audiovisual presentation.

· Be sure that the information and arguments you present are aligned with the needs of your audience.

· Review the organization of your slides for clarity.

· Proofread your slides to minimize errors that could distract the audience or make your message more difficult to understand.

 

Presentation Format and Length

You may use Microsoft PowerPoint or other suitable presentation software to create your slides. If you elect to use an application other than PowerPoint, check with your faculty to avoid potential file compatibility issues.

If using PowerPoint to create your presentation slides, you may use the  SoNHS Professional Presentation Guidelines [PPTX] as a template. Be sure that your slide deck includes the following slides:

· Title slide.

· Presentation title.

· Your name.

· Date.

· Course number and title.

· References (at the end of your presentation). Apply current APA formatting to all citations and references.

Your slide deck should consist of 8–12 slides, not including a title slide and references slide.

Ensure you provide speaker notes for each slide to fully address scoring guide criteria.

Supporting Evidence

Cite 2–4 external sources to support your strategies for working with the group you have identified and generating their buy-in, as well as for your approach to the training session, activities, and materials.

Portfolio Prompt: You may choose to save your report to your  ePortfolio

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and 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.

· Explain the impact of a new policy and practice guidelines.

· Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.

· Justify the importance of a new policy and practice guidelines with regard to improving the quality of care or outcomes related to a selected role group's work.

· Competency 4: Develop strategies to work collaboratively with policy makers, stakeholders, and colleagues to address environmental (governmental and regulatory) forces.

· Summarize evidence-based strategies for working with a selected role group to promote their buy-in and prepare them to implement a new policy and apply associated practice guidelines to their work.

· Explain a selected role group’s importance in implementing a new policy and practice guidelines.

· Determine appropriate and effective instructional content, learning activities, and materials for a training session.

· Competency 5: Produce clear, coherent, and professional written work, in accordance with Capella's writing standards.

· Deliver a persuasive, coherent, and effective audiovisual presentation.

Policy Proposal and Practice Guidelines

NHS-FPX6004 Healthcare Law and Policy

Instructor: Dr Sandra McDade

June 1, 2024

Policy Proposal and Practice Guidelines

Mercy Medical Center has been underperforming in key diabetes care benchmarks, particularly in the rates of eye and foot exams for patients with diabetes. Current metrics indicate that only 59% of diabetic patients receive eye exams, which is 14.1% below the Minnesota state average and 16.2% below the national average. Additionally, foot exam rates are at 60%, which is 22.9% below the state average and 24% below the national average (Cooksey, 2020). These deficiencies in care can lead to severe complications for diabetic patients and highlight the need for immediate intervention.

The Need to Create a Policy and Practice Guidelines

Research by the Centers for Disease Control and Prevention (CDC) and the American Diabetes Association (ADA) indicates that proper diabetes management, such as regular eye and foot exams, significantly reduces the risk of complications (ADA, 2022; CDC, 2024). Therefore, it is imperative to provide clear guidelines that support these interventions as critical components of diabetes care.

The current benchmark metrics for diabetes care at Mercy Medical Center are substantially below both state and national standards. This underperformance compromises the quality of care provided to diabetic patients and, if continued, can potentially lead to preventable complications like retinopathy and neuropathy.

Failing to address these issues can cause shortfalls, such as increased morbidity and healthcare costs, decreased patient satisfaction, and potential non-compliance with healthcare regulations. Creating policy and practice guidelines is essential to avoid health risks that can lead to severe complications, including blindness and amputations. Additionally, regulatory and financial penalties, such as loss of accreditation, can undermine care delivery methods, which is detrimental to implementing reliable health outcomes. Reputation damage is another significant risk, potentially affecting patient trust and the hospital's standing.

The ADA has published the Standards of Medical Care in Diabetes, which outlines evidence-based recommendations for diabetes care. Key standards relevant to Mercy Medical Center's improvement plan include annual comprehensive dilated eye exams and comprehensive foot exams for patients with diabetes (ADA, 2022). The Centers for Medicare & Medicaid Services (CMS) also provide guidelines for diabetes self-management and reimbursements for providers for non-face-to-face care coordination services for patients with chronic conditions like diabetes (CDC, 2024).

The Proposed Policy

The policy objective is to improve the rates of eye and foot exams among diabetic patients at Mercy Medical Center to meet or exceed state and national benchmarks (ADA, 2022; CDC, 2024). Implementation of the policy begins with an increase in staff, focusing on hiring more specialists. Enhanced training for both new and existing staff members is required to ensure they can conduct accurate and regular diabetic exams and provide patient education. Additionally, the policy will ensure the improvement of equipment access. The guideline of this policy is that equipment access shall be for healthcare providers to operate at the healthcare center and then assess areas where improvements are needed. Afterward, they shall be required to purchase additional equipment to facilitate more frequent testing. This approach will support overall healthcare improvement and address patient needs effectively.

Proper implementation will also involve integrating patient engagement through education programs to increase awareness and compliance. The proposed policy aligns with standards set forth by the ADA and complies with regulatory requirements from the Minnesota Department of Health and CMS regarding diabetes care. The standards made by the ADA are: first, glycemic control, where the ADA recommends achieving an A1C level of <7% for most adults with diabetes (ADA, 2022). Second, the proper use of medication through a combination of oral medications and/or injectable medications to achieve glycemic control (ADA, 2022). Third, regular foot care and eye care examinations. Foot care is done to detect and prevent foot ulcers, while eye care is done to detect and prevent diabetic retinopathy (ADA, 2022).

Effects of Environmental Factors on the Recommended Practice Guideline

It is imperative to integrate regulatory guidelines from CMS and state health departments that mandate regular monitoring and preventive care for diabetic patients. Non-compliance with these guidelines could result in penalties, negatively affecting funding and accreditation status (Gravagna et al., 2020). There is a mandatory need to address resource considerations to ensure the healthcare environment operates cohesively. Specifically, there is a need to hire additional specialized nurses and diabetes educators to manage the current shortfall in staff. This will require an initial financial investment for hiring, training, and purchasing necessary equipment. Although these changes will require more finances upfront, there can be long-term benefits, including improved patient outcomes, reduced healthcare costs, and avoidance of penalties. Logistically, enhanced IT systems are needed to efficiently schedule and track patient exams. These measures will ensure a comprehensive approach to managing diabetes care.

Ethical and Evidence-Based Practice Guidelines

The first evidence-based strategy is increased screening for regular eye and foot exams, which reduces the incidence of diabetic complications (ADA, 2022). The second strategy is patient education, informing patients about the importance of regular exams, thereby improving compliance with care techniques (Peimani et al., 2020). A third strategy is a multidisciplinary approach that integrates care across specialties and enhances patient outcomes (Srinivas et al., 2024). These strategies support the ethical and inclusive application of diabetes care improvements at Mercy Medical Center. This process involves training staff to be culturally sensitive and inclusive in their interactions with patients, ensuring that patients from all backgrounds feel respected and understood. Additionally, it is crucial to provide comprehensive information to patients about the benefits and risks associated with diabetes management and to obtain their informed consent when conducting research.

Importance of Stakeholders and Group Involvement

Relevant stakeholders include healthcare providers, patients, and administrative staff. Their involvement is imperative to gain insights into how operations in the healthcare environment are performed. Building support from these stakeholders ensures the smoother implementation of relevant healthcare operations. When stakeholders and groups are involved, the outcomes include additional training and workload adjustments for nurses and educators, enhancing their ability to provide culturally competent care. Patients will experience improved health outcomes and increased satisfaction with their care. When stakeholders within the administration generate financial changes to adhere to policy guidelines, the result will be long-term savings, improved patient outcomes, and compliance with regulatory standards.

Strategies for Stakeholder Collaboration

For healthcare providers, the relevant strategies include tracking compliance efforts, implementing guidelines, and providing patient education. For administrative staff, the appropriate strategies are policy adherence and resource allocation. For patients, the relevant strategy is active participation in their care plans and providing feedback. Successful implementation of the policy relies on adherence and teamwork, encouraging everyone to perform better.

Improving diabetes care benchmarks at Mercy Medical Center requires policy changes, enhanced training, and stakeholder engagement. These measures will address the current shortfalls in eye and foot exam rates. There will be an overall improvement in patient outcomes as everyone complies with regulatory standards and maintains the center’s reputation for providing high-quality care.

References

ADA. (2022). American diabetes association releases 2023 standards of care in diabetes to guide prevention, diagnosis, and treatment for people living with diabetes. Retrieved 28 May 2024 from https://diabetes.org/newsroom/american-diabetes-association-2023-standards-care-diabetes-guide-for-prevention-diagnosis-treatment-people-living-with-diabetes .

CDC.Gov. (2024). Medicare reimbursement guidelines. Retrieved 28 May 2024 from https://www.cdc.gov/diabetes-toolkit/php/reimbursement/medicare-reimbursement-guidelines.html

CDC.Gov. (2024). National diabetes statistics report. Retrieved 28 May 2024 from https://www.cdc.gov/diabetes/php/data-research/index.html#:~:text=Prevalence%20of%20both%20diagnosed%20and,Table%201a%3B%20Table%201b ).

Cooksey, C. (2020). Strategies to improve annual diabetic foot screening compliance at a family clinic. Clinical Diabetes: A Publication of the American Diabetes Association, 38(4), 386-389. https://doi.org/10.2337/cd20-0030

Gravagna, K., Becker, A., Valeris-Chacin, R., Mohammed, I., Tambe, S., Awan, F. A., Toomey, T. L., & Basta, N. E. (2020). Global assessment of national mandatory vaccination policies and consequences of non-compliance. Vaccine, 38(49), 7865. https://doi.org/10.1016/j.vaccine.2020.09.063

Peimani, M., Nasli-Esfahani, E., & Sadeghi, R. (2018). Patients’ perceptions of patient–provider communication and diabetes care: A systematic review of quantitative and qualitative studies. Chronic Illness. https://doi.org/10.1177/1742395318782378 .

Srinivas, V., Choubey, U., Motwani, J., Anamika, F., Chennupati, C., Garg, N., Gupta, V., & Jain, R. (2024). Synergistic strategies: optimizing outcomes through a multidisciplinary approach to clinical rounds. Proceedings (Baylor University. Medical Center), 37(1), 144-150. https://doi.org/10.1080/08998280.2023.2274230