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NHS FPX 6004 Assessment 2 Policy Proposal

Student Name

Capella University

NHS-FPX 6004 Health Care Law and Policy

Prof. Name


Introduction to Policy Proposal

The underperformance observed in Mercy Medical Center (MMC) in the previous assignment is inadequate foot examinations and HBA1c tests. It is also identified that these benchmarks are essential in improving diabetes management and treatment. AHRQ indicators also highlighted the optimal benchmark for these two tests which concluded the importance of foot exam and HBA1c testing in pre-diabetics and diabetic patients. 

This assessment is based on proposing a policy and practice guidelines that will help in improving the quality of care and performance of the organization in terms of the underperformance of the benchmarks. It will highlight the role of leaders to develop a policy that will enable the interprofessional team to work collaboratively for resolving the relevant issues related to the performance. This will eventually bring changes in the healthcare system improving the quality and safety of healthcare. 

Need for Policy and Practice Guidelines to Address Benchmark Underperformance

The need for healthcare policies and practice guidelines in healthcare organizations can be understood as it helps in establishing standards that eventually benefit patients, healthcare organizations, and the overall healthcare system. This also helps in improving poor outcomes related to healthcare issues. Similarly to address the benchmark underperformance, it is essential to develop policies and practice guidelines. 

According to the data evaluated from MMC and national benchmarks as described in previous assessments, foot examinations lie at 40% and 42% respectively in the year 2019 and 2020, which according to the national benchmark should be at 84%. Similarly, for HBA1c levels, the tests performed in 2019 and 2020 are 37.3% and 48.3%, correspondingly which is different from the national benchmark as it stays at 79.5% (AHRQ, n.d.).

NHS FPX 6004 Assessment 2 Policy Proposal

These results showed that patients are less involved in their self-management of diabetic states. Diabetes is a disease that has no specific cure, however, the complications can be reduced using appropriate self-management methods. A study to determine the prevalence of poor diabetes self-management in Ethiopian patients concluded that 1 out of 2 diabetic patients lack the behaviors of self-managing their diseases (Habebo et al., 2020). The results from such studies and the Mercy Medical Center’s databases on the reduced number of foot examinations and HBA1c tests advocate the need for the development and implementation of policies using evidence-based strategies as these results are showing poor outcomes on patients’ health, delayed treatment, reduced patients’ satisfaction, increased healthcare costs, and eventually leading to poor quality of life. 

The purpose of this policy proposal is to establish standard methodologies which will help the organization to regularly perform foot examinations and HBA1c tests of diabetic and non-diabetic patients to lower the burden of the disease and improve outcomes by reducing complications. If the problems are not addressed adequately, it may lead to severe complications for the patients which may hinder their lives, cause a financial burden, reduce their well-being, and may cause mortality (Sayeed et al., 2020). 

Summary of Proposed Policy and Guidelines 

In MMC, it is crucial to implement new policies and standard guidelines to improve foot examinations and HBA1c tests for diabetic patients. Mercy Medical Center should develop a policy for the timelines of foot screening among patients with diabetes and diabetic complications. These timelines should be based on the evidence-based recommendations by the International Working Group on Diabetic Foot (IWGDF), which states that foot screening must be done once a year for patients with no incidences of peripheral neuropathy whereas, for patients with peripheral neuropathy, it is recommended to get foot screened every six months.

Moreover, it is recommended that patients with peripheral artery disease, or foot deformity should get it checked every three to six months and those with a leg amputation or pedal ulceration should visit every one to three months (Song & Chambers, 2022). Similarly for the HBA1c, MMC can follow the guidelines suggested by CDC. These standard guidelines define the frequency of HBA1c tests accordingly: 

  1. A baseline HBA1c test is required for adults over 45 years of age, or if they are underage but overweight and have any risk factors related to diabetes. 
  2. Repeating the test every 3 years is required for adults over 45 years with risk factors.
  3. Repeat the test every 1 to 2 years if you fall in the range of prediabetes. 
  4.  For patients already diagnosed with diabetes, tests should be performed at least twice a year (CDC, 2022). 

NHS FPX 6004 Assessment 2 Policy Proposal

Some of the environmental factors that have potential effects on the recommended guidelines are tax exemption and compliance, staffing issues, lack of finances and logistics, and data breaches. Mercy Medical Center may require to fulfill the criteria of the Patient Protection and Affordable Care Act to make their care exempted from taxes (Crowley & Bornstein, 2019). This tax-tax exemption will help them to ensure that the number of foot examinations and HBA1c tests is increased according to the proposed policies.

Moreover, adequate staffing and resources (finances and logistics) will help in enhancing patient education and performing the tests as per the practice guidelines which will ensure effective performance against national benchmarks. Data breaching is one of the most important aspects that MMC needs to focus on related to the tests performed. Showing HIPAA (protection of patient’s information through security, privacy, and confidentiality laws) (CDC, 2022) compliance will help MMC to build patients’ trust eventually involving them in self-management of diabetes through frequent testing and examinations. 

Evidence-Based Practice Guidelines

Various researchers have been studying the causes of diabetic complications for a long time. They have identified evidence-based strategies that can be implemented to increase the number of foot examinations and HBA1c tests. These strategies will help in reducing the complications of diabetes. These changes include adhering to treatment plans and performing regular screening of the feet and HBA1c levels. Many researchers have identified these two benchmarks to be essential components in the treatment of diabetes as they would help to further reduce the complication of the diabetic foot and aggravate the disease to other vital organs (Kaiafa et al., 2020; Song & Chamber, 2023).

The strategy involves providing education and support to the patients to make lifestyle changes that will promote their well-being and enhance self-management of diabetes to improve the quality of care through multidisciplinary collaboration. The establishment of guidelines for improving foot exams and HBA1c tests will reduce the likelihood of complications from diabetes (Geng et al., 2023). This strategy is also based on ethical principles as it fully substantiates patients’ autonomy and involvement in the care process. Moreover, this follows the principle of beneficence, where healthcare providers will collaboratively work to benefit patients and improve their health outcomes. 

Another evidence-based strategy to increase the number of HBA1c tests is introducing point-of-care testing the in organization. A study point of care testing and HBA1c tests concluded that POCT ensures regular checkups of blood glucose testing and it also mentions that patients have shown positive experiences through this strategy in the management of their diabetes (Smits et al., 2022). This strategy is ethically sound as it benefits diabetic patients and it will be introduced for all the patients following the ethical principle of justice. 

Creating an Organizational Policy

To enhance the management of diabetes and reduce the likelihood of complications, it is necessary to implement changes in organizational policies. A key strategy in these policies should be ensuring appropriate staffing levels and staff education specifically for nurses. This will help in maintaining an adequate nurse-patient ratio as well as nurses will be able to effectively transfer their knowledge to the patients related to diabetes management (Piya et al., 2022). Appropriate staffing and adequate training and education will ensure that patients are managed effectively without excessive workload.

This will also provide nurses with effective time to address patients’ concerns and provide individualized education to them. Consequently, the goal of addressing and improving foot exams and HBA1c tests will be fulfilled. Additionally, promoting patient confidentiality as per the rules of HIPAA law and fostering a multidisciplinary collaborative environment can also facilitate coordinated care for the patients and maintain high-quality standards. These measures aim to promote healthier lives for people with diabetes and decrease the risks associated with the condition.

Stakeholder Involvement in Implementing Proposed Strategies

The successful implementation of the policy at Mercy Medical Center relies heavily on the willingness of the leadership and staff to embrace change. An interdisciplinary group comprising experts from different healthcare organizations with expertise in diabetic management will play a crucial role. The nursing directors will play the role of key stakeholders, whereby, they will provide essential information to meet the recommended assessment standards. The interprofessional team from the hospital will be actively involved in the implementation process which includes doctors, nurses, laboratory personnel, health educators, administrators, and policymakers.

The project will be led by a dedicated team to ensure its achievement of the desired objectives. Nurses and doctors play a central role in the implementation of the policy. Being the frontline staff, they will be responsible to show compliance with the standard guidelines development to ensure the number of foot exams and HBA1c is improved. This is possible due to the training and education that nurses and doctors will receive on the appropriate management of diabetic patients. Also, they will be responsible for patient education and appropriate response to the patient’s condition. 

Collaboration Strategies with the Stakeholders 

The strategies that can be equipped for effective collaboration with stakeholders are:

  • Considering stakeholders as communication partners whereby the communication between the interprofessional team, and internal and external stakeholders should be transparent and effective. These effective partnerships will help organizations to achieve desired outcomes by working together as compared to working individually. Sharing similar goals, resources, competencies, and benefits is essential to strengthening these partnerships through transparent and effective communication (Loban et al., 2021). 
  • Inclusivity of stakeholders is essential where all the team members are involved in the process of development. This inclusivity will ensure that team members enjoyed their chances of building a consensus on the provisions of the policies, goals, and values, which will help in the implementation phase (Masefield et al., 2021). Since the development of policies involved all team members, they will be highly productive while implementing the policies to ensure that the goals and the purposes are achieved. 


To sum up, inadequate foot and HBA1c tests have a substantial impact on the high morbidity and mortality rate in diabetic patients. Neglecting these evaluations can lead to financial instability, diminished quality of life, and lower levels of patient satisfaction. Mercy Medical Center needs to make a firm commitment to mitigate the risk of diabetes complications by enforcing mandatory examinations, policies, and practice guidelines. The success of this policy hinges on the willingness of the medical center’s leadership and staff to embrace change and prioritize the implementation of these essential evaluations. By doing so, Mercy Medical Center can significantly enhance patient outcomes, improve diabetes management, and foster healthier lives with reduced complications for those affected by the disease.


AHRQ. (n.d.). National Healthcare Quality and Disparities Reports (NHQDR). NHQDR Data Tools | AHRQ Data Tools. Retrieved from. 

Centers for Disease Control and Prevention. (2022, June). Health Insurance Portability and accountability act of 1996 (HIPAA). Centers for Disease Control and Prevention. 

Centers for Disease Control and Prevention. (2022, September). All about your A1C. Centers for Disease Control and Prevention. 

Crowley, R. A., & Bornstein, S. S. (2019). Improving the patient protection and affordable care act’s insurance coverage provisions: A position paper from the American College of Physicians. Annals of Internal Medicine170(9), 651. 

Geng, T., Zhu, K., Lu, Q., Wan, Z., Chen, X., Liu, L., Pan, A., & Liu, G. (2023). Healthy lifestyle behaviors, mediating biomarkers, and risk of microvascular complications among individuals with type 2 diabetes: A cohort study. PLOS Medicine20(1). 

Habebo, T. T., Pooyan, E. J., Mosadeghrad, A. M., Babore, G. O., & Dessu, B. K. (2020). Prevalence of poor diabetes self-management behaviors among Ethiopian diabetes mellitus patients: A systematic review and meta-analysis. Ethiopian Journal of Health Sciences, 30(4), 623–638. 

NHS FPX 6004 Assessment 2 Policy Proposal

Kaiafa, G., Veneti, S., Polychronopoulos, G., Pilalas, D., Daios, S., Kanellos, I., Didangelos, T., Pagoni, S., & Savopoulos, C. (2020). Is hba1c an ideal biomarker of well-controlled diabetes? Postgraduate Medical Journal97(1148), 380–383. 

Loban, E., Scott, C., Lewis, V., & Haggerty, J. (2021). Measuring partnership synergy and functioning: Multi-stakeholder collaboration in Primary Health Care. PLOS ONE16(5). 

Masefield, S. C., Msosa, A., Chinguwo, F. K., & Grugel, J. (2021a). Stakeholder engagement in the health policy process in a low-income country: A qualitative study of stakeholder perceptions of the challenges to effective inclusion in Malawi. BMC Health Services Research21(1). 

Piya, M. K., Fletcher, T., Myint, K. P., Zarora, R., Yu, D., & Simmons, D. (2022). The impact of Nursing Staff Education on diabetes inpatient glucose management: A pilot cluster randomised controlled trial. BMC Endocrine Disorders22(1). 

Sayeed, K. A., Qayyum, A., Jamshed, F., Gill, U., Usama, S. M., Asghar, K., & Tahir, A. (2020). Impact of diabetes-related self-management on glycemic control in type II diabetes mellitus. Cureus. 

Smits, M., Hopstaken, R., Terhaag, L., de Kort, G., & Giesen, P. (2022). Early experiences with quality-assured hba1c and professional glucose point-of-care testing in general practice: A cross-sectional observational study among patients, nurses and doctors. BMC Nursing21(1).

Song, K., & Chambers, A. R. (2022). Diabetic foot care. In StatPearls. StatPearls Publishing.