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Assessment 2: Policy Proposal

Assessment 2: Policy Proposal


Draft a written proposal and implementation guidelines for an organizational policy that you believe would help lead to an improvement in quality and performance associated with the benchmark metric for which you advocated action in Assessment 1.Assessment 2: Policy Proposal

Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.Assessment 2: Policy Proposal

In 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 guidelines change proposals that will enable a team, unit, or the 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.Assessment 2: Policy Proposal

Assessment Instructions

In this assessment, you will build on the dashboard benchmark evaluation work you completed in Assessment 1.


After reviewing your benchmark evaluation, senior leaders in the organization have asked you to draft a policy change proposal and practice guidelines addressing the benchmark metric for which you advocated action.Assessment 2: Policy Proposal

In their request, senior leaders have asked for a proposal of not more than 2–4 pages that includes a concise policy description (about one paragraph), practice guidelines, and 3–5 credible references to relevant research, case studies, or best practices that support your analysis and recommendations. You are also expected to be precise, professional, and persuasive in justifying the merit of your proposed actions.

When creating your policy and guidelines it may be helpful to utilize the template that your current care setting or organization uses. Your setting’s 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 care setting does not have these resources, there are numerous appropriate templates freely available on the Internet.


Note: The tasks outlined below correspond to grading criteria in the scoring guide.Assessment 2: Policy Proposal

In your proposal, senior leaders have asked that you:Assessment 2: Policy Proposal

  • 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.Assessment 2: Policy Proposal
  • 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?


    The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The NHS-FP6004 – Health Care Policy and Law Library Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you.Assessment 2: Policy Proposal

    Ethical Decision-Making to Improve Quality Performance

    This interactive media applies an ethical decision-making process to a workplace health care issue in a hypothetical scenario, which may give you some ideas about how to incorporate ethical considerations into your policy change.

    This short briefing outlines issues related to quality-related policy development and the potential solutions offered by new regulations such as the Medicare Access and CHIP Reauthorization Act (MACRA) and the ACA.


Unformatted Attachment Preview

Running head: POLICY PROPOSAL 1 Policy Proposal Learner’s Name Capella University Health Care Law and Policy Policy Proposal May, 2019 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. POLICY PROPOSAL 2 Policy Proposal Despite being recognized as one of the region’s top choices for health care, Mercy Medical Center has areas for opportunity. Medication errors in the medical and surgery unit have seen a 50% increase from 4 in 2015 to 8 in 2016. Nute suggests that medication errors may result in longer hospital stays and higher rates of mortality and morbidity (as cited in Kavanagh, 2017). According to Rafter, Hickey, Conroy, Condell, O’Connor, Vaughan, Walsh, and Williams, these errors may result in an increase in the cost of health care (as cited in Kavanagh, 2017). Incidents resulting from medication errors require additional resources and more care interventions, which leads to a decrease in the efficiency of health care services provided. Considering the expense medication errors can entail for patients and health care practitioners, there is a need for an organizational policy to address the shortfall in the reduction of medication errors. Strategies to Resolve Medication Errors Medication Error Analysis According to Zhan, Smith, Keyes, Hicks, Cousins, and Clancy, because of the fear of repercussions such as disciplinary action being taken, a large number of medication errors go unreported (as cited in Weant, Bailey, & Baker, 2014). However, learning from these errors will help reduce their recurrence and improve care interventions. Every reported error is an opportunity for the development of a countermeasure and will help avoid or reduce the impact of the same error in the future (Weant et al., 2014).Assessment 2: Policy Proposal
A health care system that exposes patients to medical errors needs to be critically evaluated. Failure mode and effects analysis is a technique that can be used to analyze incidents related to medication errors. Under this method of analysis, the medical center can commission the formation of a multidisciplinary committee that will review processes susceptible to errors. Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. Commented [A1]: Good introduction that meets the goal of “explaining the need for the organizational policy.” POLICY PROPOSAL 3 Based on the inadequacies observed, the committee can classify the medication errors according to the priority in which they need to be addressed (Weant et al., 2014). As part of the analysis, the committee will review the steps in the process, the things that could go wrong, the reasons behind them, and the possible repercussions (Institute for Healthcare Improvement, n.d.). Based on these factors, the committee can recommend actions to reduce the possible errors in the process. The analysis will end with an evaluation of the prescribed actions for improvement (Centers for Medicare and Medicaid Services, n.d.). Automated Dispensing Cabinets An automated dispensing cabinet is a computerized medication distribution system that is installed in patient care units. It stores, dispenses, and electronically tracks drugs at the point of care. Using these cabinets can help the medical center profile patients, reduce the time taken to retrieve medication, and track inventory on a real-time basis (Weant at al., 2014). These cabinets usually contain high-alert and controlled medications and can only be accessed using an ID and a password. With the use of these cabinets, nurses will not have to walk long distances to collect the required medication (Rochais, Atkinson, Guilbeault, & Bussières, 2014). The implementation of both these strategies can be affected by certain environmental factors. The efficacy of medication error analysis can be affected if error incidents are underreported or if errors are incorrectly documented. Barach and Small state that error incidents are usually reported verbally despite how frequently they occur. This can lead to an underreporting of errors (as cited in Elden & Ismail, 2016). Moreover, verbally communicating errors can lead to errors in documenting data. According to Claudia, Sharon, DeVSP, Merrell, and Gail, the scope for the improvement of patient safety will be limited if errors are discussed verbally (as cited in Elden & Ismail, 2016). With regard to the use of automated dispensing Copyright ©2018 Capella University. Copy and distribution of this document are prohibited.Assessment 2: Policy Proposal
POLICY PROPOSAL 4 cabinets, incorrect restocking is one of the problems that can arise, which can result in treatment delays. Apart from this, inaccurate documentation of doses retrieved from the automated cabinets can also affect timely treatment. This can lead to incorrect administration of medication (Hamilton-Griffin, 2016). Additionally, when care providers such as nurses are affected by heavy workloads and are preoccupied with various tasks at once, they are likely to get interrupted or distracted while collecting and administering medication from the cabinets. To ensure that these issues do not arise, the pharmacy can be asked to share an updated list of the stock on a daily basis. A staff member or nurse can be tasked to cross-check the cabinet stock against the list provided by the pharmacy. Further, reassessing the stock from time to time and using barcode technology for restocking medications can also reduce the possibility of such errors occurring (Pennsylvania Patient Safety Authority, n.d.). Clinicians need to be provided with continuous education on new drugs, procedures, and policies so that the proposed strategies are effectively implemented. Apart from that, creating simulation environments will also instill confidence in care providers about their competency in medication administration. It is necessary to create a culture of safety within the organization, which will allow care providers to freely report errors without the fear of negative consequences and coercion. Policy for Managing Medication Errors Policy Statement Medication errors pose a risk to patient safety and public health. This policy is a guide for health care practitioners to enable them to take appropriate action in the event of a medication error.
Assessment 2: Policy ProposalThe guidelines and recommendations will provide a framework to improve the practice of the two proposed evidence-based strategies. Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. POLICY PROPOSAL 5 Scope The policy applies to nursing staff, medical staff, emergency and allied care practitioners, and staff employed at the pharmacy. All concerned individuals are responsible for the prescription, dispensation, and administration of medicines. Guidelines for Implementing Evidence-Based Strategies The multidisciplinary local patient safety committee (which includes professionals from various disciplines such as nursing, pharmacy, and medicine) should regularly go over the existing action plan to improve health care outcomes. The committee must assess apprehensions and go over events that possibly endanger patient safety. It should also analyze trends in medication errors as well as address systemic weaknesses (Polnariev, 2016).Assessment 2: Policy Proposal
According to Schlesselman, around half of all possible medication error events can be averted by patient education. Pharmacists can counsel patients when they are visited for consultations. Training sessions on counseling patients will aid the effectiveness of pharmacists’ consultations. These training sessions should include an emphasis on asking open-ended questions to patients (as cited in Polnariev, 2016) such as the following three prime questions: (1.) What did the physician tell you the medication is for?, (2.) How did the physician tell you to take the medication?, and (3.) What did the physician tell you to expect? The sessions should also emphasize listening to patients patiently, learning to identify inaccuracies in their responses, and demonstrating to them the use of medication devices (Lauster & Srivastava, 2013). Before the administration of any medication, a review of medication orders by a pharmacist will ensure the safety of the hospital’s medication system. Barcode verification should be put in place for the stocking of medications. Limited amounts of medication should be placed in the cabinets, and the cabinets should be refilled frequently (Hyland, Koczmara, Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. Commented [A2]: I think the idea of the multidisciplinary team is good; the active involvement of all key stakeholders will be critical to success. POLICY PROPOSAL 6 Salsman, Musing, & Greenall, 2007). For the nursing staff, barcode verification will validate the 7 rights of medication administration: right patient, right drug, right dose, right time, right route, right reason, and right documentation. These 7 rights will be verified while administering medication. A nurse will scan the barcode on his or her identification badge, on the patient’s wristband, and on the medication. Software will analyze the real-time data, and based on the database, it will generate approvals or warnings (Shah, Lo, Babich, Tsao, & Bansback, 2016). When choosing and placing medications within automated dispensing cabinets, products that look alike should not be placed inside the same multiple-product drawer. Medications should be retrieved from the cabinet for one patient at a time and administered without delay. Training sessions about the right practices related to the use of automated dispensing cabinets should be organized for the staff. The staff must be educated about unsafe practices that can affect patient outcomes negatively such as retrieving medications in advance and retrieving medications for multiple patients. They must also be educated about the need to report problems such as similar drug name pairs being displayed on the drug selection screens on the cabinets (Hyland et al., 2007). Stakeholder Involvement in Implementing Proposed Strategies Assistance can be sought from key administrative personnel such as the chief executive officer, director of nursing, or chief operating officer. These individuals can form a quality committee where they can share their expertise and monitor the effective implementation of the proposed strategies. By establishing role accountability and articulating the organization’s quality improvement norms from time to time, the key administrative personnel can reinforce a culture of safety among the health care staff (Parand, Dopson, Renz, & Vincent, 2014). The main nursing staff should also be involved because they deal with a lot of medication administration Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. POLICY PROPOSAL 7 problems firsthand. They can help in the identification of the inadequacies that cause medication errors (Blake, 2017). While receiving prescriptions at the pharmacy, pharmacists can check for discrepancies and contact the prescribers for any changes in orders before the prescriptions are filled out (The Health Foundation, 2012). The involvement of the hospital administration and the care providers will lead to transparency in the implementation of the strategies. It will bring in multidisciplinary expertise, create room for debate and discussion, and ensure that the parties involved have a say in decisions concerning these strategies. Therefore, a partnership between the hospital administration and the care providers will ensure that the proposed strategies are implemented effectively. Conclusion Incidents resulting from medication errors can reduce a health care organization’s efficiency. However, the implementation of medication error analysis and the use of automated dispensing cabinets can substantially reduce the chances of such errors occurring. Above all, the most important thing for the proposed policy to be effective is the creation of a culture of safety and quality improvement at Mercy Medical Center. Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. POLICY PROPOSAL 8 References Blake, R. W. (2017). Reducing medication errors through workflow redesign. Journal of Nursing & Interprofessional Leadership in Quality & Safety, 1(2), 5. Retrieved from https://digitalcommons.library.tmc.edu/cgi/viewcontent.cgi?referer=https://www.google.c om/&httpsredir=1&article=1006&context=uthoustonjqualsafe Centers for Medicare and Medicaid Services. (n.d.). Guidance for performing failure mode and effects analysis with performance improvement projects. Retrieved from https://cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/downloads/GuidanceForFMEA.pdf Elden, N. M. K., & Ismail, A. (2016). The importance of medication errors reporting in improving the quality of clinical care services. Global Journal of Health Science, 8(8), 243–251. Retrieved from https://ncbi.nlm.nih.gov/pmc/articles/PMC5016354/ Hamilton-Griffin, K. (2016). Developing improvement strategies on the use of automated dispensing cabinets to reduce medication errors in a hospital setting (Doctoral dissertation). Retrieved from https://search-proquestcom.library.capella.edu/docview/1810160234?pq-origsite=summon Hyland, S., Koczmara, C., Salsman, B., Musing, E. L. S., & Greenall, J. (2007). Optimizing the use of automated dispensing cabinets. The Canadian Journal of Hospital Pharmacy, 60(5), 332–334. Retrieved from https://www.ismpcanada.org/download/cjhp/cjhp0711.pdf Institute for Healthcare Improvement. (n.d.). Failure modes and effects analysis. Retrieved from http://ucdenver.edu/academics/colleges/medicalschool/facultyAffairs/moc/Forms/Docum ents/MOCPAP/FailureModesandEffectsAnalysis_IHI.pdf Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. POLICY PROPOSAL 9 Kavanagh, C. (2017). Medication governance: Preventing errors and promoting patient safety. British Journal of Nursing, 26(3), 159–165. Retrieved from http://library.capella.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=ccm&AN=121207143&site=ehost-live&scope=site Lauster, C. D., & Srivastava, S. B. (2013). Fundamental skills for patient care in pharmacy practice. Retrieved from https://books.google.co.in/books?id=r4xBNa57WkC&pg=PA161&lpg=PA161&dq=Indian+Health+Service%E2%80%99s+% E2%80%9CThree+Prime+Questions%E2%80%9D&source=bl&ots=e7FJ3mTty0&sig=d JGwJMF6C2qUI-aNlKX_qSSpSvY&hl=en&sa=X&ved=2ahUKEwibhI6s0neAhWHv48KHZmPCv0Q6AEwBnoECAUQAQ#v=onepage&q=Indian%20Health%20 Service%E2%80%99s%20%E2%80%9CThree%20Prime%20Questions%E2%80%9D&f =false Parand, A., Dopson, S., Renz, A., & Vincent, C. (2014). The role of hospital managers in quality and patient safety: A systematic review. BMJ Open, 4(9). Retrieved from https://ncbi.nlm.nih.gov/pmc/articles/PMC4158193/ Pennsylvania Patient Safety Authority. (n.d.). Problems associated with automated dispensing cabinets. Retrieved from http://patientsafety.pa.gov/ADVISORIES/documents/200509_21.pdf Polnariev, A. (2016). Using the medication error prioritization system to improve patient safety. Pharmacy and Therapeutics, 41(1), 54–59. Retrieved from https://ncbi.nlm.nih.gov/pmc/articles/PMC4699487/#__ffn_sectitle Rochais, É., Atkinson, S., Guilbeault, M., & Bussières, J.-F. (2014). Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. POLICY PROPOSAL 10 health care center. Journal of Pharmacy Practice, 27(2), 150–157. Retrieved from https://journals-sagepub-com.library.capella.edu/doi/10.1177/0897190013507082 Shah, K., Lo, C., Babich, M., Tsao, N. W., & Bansback, N. J. (2016). Bar code medication administration technology: A systematic review of impact on patient safety when used with computerized prescriber order entry and automated dispensing devices. The Canadian Journal of Hospital Pharmacy, 69(5), 394–402. Retrieved from https://ncbi.nlm.nih.gov/pmc/articles/PMC5085324/ The Health Foundation. (2012). Evidence scan: Reducing prescribing errors. Retrieved from https://health.org.uk/sites/default/files/ReducingPrescribingErrors.pdf Weant, K. A., Bailey, A. M., & Baker, S. N. (2014). Strategies for reducing medication errors in the emergency department. Open Access Emergency Medicine, 6, 45–55. Retrieved from https://ncbi.nlm.nih.gov/pmc/articles/PMC4753984/#__ffn_sectitle Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. …