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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:


Policy Proposal

We evaluated Mercy Medical Center’s (MMC) dashboard metrics against national and state benchmarks by the Agency for Healthcare Research and Quality (AHRQ). The results showed that MMC is shortfalling in all three diabetes screening tests – eye tests, foot examination, and HBA1c levels. However, the feet examination had a significant variance from the established benchmarks. In this paper, we develop policy and practice guidelines to address underperformance, improve the quality of care, and minimize patient safety risks. 

Need for Policy and Practice Guidelines to Address Underperformance 

The established benchmark for foot examination in diabetic patients is 84% nationally and 8.7.7% at the state level. Contrastingly, the MMC numeric data shows only 40-42% of foot examinations were conducted in 2019 and 2020. This significant difference advocates the need for standardized policy and practice guidelines, which ensure the quality of care, minimize safety risks, and improve the organization’s performance.

This underperformance in diabetes patients negatively influences the quality of care by hampering the early detection of complications such as neuropathy and diabetic foot ulcers. Timely identification of these issues is essential to prevent the progression of these complications into infections, further leading to increased leg pain, decreased mobility, and amputation (Carmichael et al., 2021). Failure to meet these benchmark standards demonstrates the lack of comprehensive care, diminishing patient trust and satisfaction. 

NHS FPX 6004 Assessment 2 Policy Proposal

On the other hand, this underperformance increases the demand for medical interventions and extends hospital stays, straining the organization’s financial and human resources. The heightened costs related to complex and extensive treatment comprise the effective operations of the organization (Moucheraud et al., 2019). Moreover, diminished patients’ trust increases reputational risks, affecting the organization’s position in the healthcare industry. However, undressed underperformance of foot examinations has several repercussions for diabetic patients.

Delayed detection and intervention results in severe complications, advancing the disease, increasing healthcare costs for individuals and the organization, and deteriorating quality of life for patients. Continued non-compliance with standardized benchmarks may jeopardize an organization’s accreditation, affecting internal and external collaborations and eligible reimbursements (Hussein et al., 2021). Thus, MMC stakeholders should advocate for profound policy and practice guidelines to ensure the successful implementation of foot examinations, preventing individual and organizational risks. 

Policies and Procedures for the Organization

Based on the guidelines from the Centers for Medicare & Medicaid Services (CMS) and the American Diabetes Association (ADA), we established a policy for MMC to address underachieved foot examinations. The policy is as follows:

“The organization must conduct annual comprehensive foot examinations for type I and type II diabetic patients to recognize the predictive factors for foot ulcers and diabetic neuropathy. These examinations should include foot inspection, checking for the pulses, and testing foot sensations” (CMS, n.d.). The practice guidelines for comprehensive foot examination include patients’ history and general exam, neuropathy assessment, vascular assessment, and referral/follow-up. 

  • Patient History and General Exam: Healthcare providers must gather data on any past ulcerations or amputations and history of peripheral vascular disease. Moreover, they should assess patients’ renal function and foot assessment to check for disorders and deformities, respectively (ADA, n.d.). 
  • Neuropathy Assessment includes assessing foot sensations using tuning fork vibration, ankle reflexes, and Vibration Perception Threshold (VPT). VPT is a foremost assessment measure for diabetic patients to assess peripheral neuropathy by identifying sensitivity issues (ADA, n.d.). 
  • Vascular Assessment: Evaluating foot pulses is essential as a lack of pulses reflects the signs of diabetic neuropathy and lack of tissue perfusion (ADA, n.d.).

NHS FPX 6004 Assessment 2 Policy Proposal

  • Referral or Follow-up: Healthcare providers should decide whether the patient needs a referral or a follow-up based on risk categories (RC) after performing all these assessments. These are subdivided into four categories – RC 0 = no risk of diabetic neuropathy, which means the patient will have the annual examination; RC 1= loss of protective sensation where the patient must undergo foot examination every three to six months; and RC 2 = this includes loss of sensation along with deformities and peripheral vascular disease. In this case, the organization must conduct a test every 2-3 months and refer the patient to a vascular specialist. Lastly, RC 3 = patient has a previous history of ulceration or amputation and must get a foot examination by experts every 1-2 months (Nduati et al., 2022). 

Various regulatory considerations, including reimbursement and penalty procedures by CMS, influence these recommended practice guidelines. CMS defines some quality measures that impact Medicare reimbursement for the organizations. Non-compliance with these measures can lead to several penalties, one under the Hospital Readmissions Reduction Program (HRRP). As per this program, organizations are obliged to reduce unnecessary hospital admissions. Failure to do so results in reduced reimbursement rates and additional forfeits (CMS, 2023). When practicing comprehensive foot examination, MMC, according to the proposed practice guidelines, will show adherence to the program provisions, ensuring they receive financial incentives.

Other environmental factors that impact these practice guidelines include staff training and education, adequate finances and logistics to perform foot examinations, and an appropriate number of human resources to dedicate workload and ensure seamless operations of the proposed policy and practice guidelines. The availability of human resources and ongoing training and education prepare sufficient, competent, and qualified teams to conduct appropriate foot examinations. Similarly, financial and logistic resources are essential for the smooth scheduling of these tests, addressing the underperforming benchmark, and maintaining the sustainability of the organizational changes. 

Strategies from the Literature for Ethical Evidence-Based Practice

Integrating Electronic Health Records (EHR) systems and patient education are two effective, ethically grounded, evidence-based strategies to improve the underperformance of foot examinations in diabetic patients. 

Integration of EHR systems

Integrated EHR systems with clinical decision-making tools improve patient outcomes, maintain care coordination, and enhance care continuity. These systems can be utilized by stakeholders (healthcare professionals, administrators, and the quality assurance team) to communicate and exchange patient data (Lessing & Hayman, 2019). Documentation of foot examinations, scheduling appointments, and making holistic decisions about patients’ risk of diabetic neuropathy are three significant jobs these health information technologies can perform, addressing the shortfall and improving the quality of care.

Integrated EHR systems must comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations to maintain patients’ privacy and ensure sensitive patient health information security through robust security measures, end-to-end encryption, and access controls (Basil et al., 2022). By complying with HIPAA policy, this strategy adheres to ethical principles of protecting patient privacy and ensuring informed consent while sharing patients’ data within the organization. Moreover, the staff using EHR systems should be trained in cultural competency to address the needs of patients from various cultural backgrounds.

Patient Education

Another evidence-based strategy is engaging patients in their healthcare journey. According to Guy (2022), well-informed and adequately engaged patients are more likely to participate in preventive care for their diabetes. This improves adherence to foot examination appointments, eventually improving the shortfall benchmark. This strategy complies with the national policy of the Affordable Care Act (ACA), stressing preventive care to minimize healthcare costs and reduce hospitalizations (CMS, n.d.).

Patient education reflects informed decision-making and cultural sensitivity. While the education materials should empower individuals to make knowledgeable decisions about their health, recognizing their autonomy and preferences, they should be accessible for patients with language barriers. It must cater to diverse cultural beliefs and practices. 

The implementation of these initiatives impacts stakeholders’ workflow and job requirements. Healthcare professionals such as physicians and nurses should focus on adapting to the technology. This entails the additional task of arranging robust training and education from organizations’ administrators. Meanwhile, the leaders work together to allocate resources strategically to integrate EHR systems and develop culturally inclusive patient education materials. Quality compliance teams monitor and ensure adherence to policy and practice guidelines, improving the overall quality of healthcare services and ensuring the sustainability of the initiatives.

 Stakeholders’ Participation in Policies and Guidelines

The participation of these stakeholders is imperative for the effective development and successful implementation of the policy and practice guidelines. Firstly, the diverse perspectives, for instance, are an essential benefit of engaging interprofessional team members. Involving various stakeholders ensures that the policy considers diverse viewpoints, integrating care for groups and populations from diverse backgrounds. This will eventually result in the desired outcomes and improved performance by the organization (Gomez & Bernet, 2019). Furthermore, participation from various stakeholders cultivates a sense of ownership and promotes active commitment to the initiative.

This is crucial to gauge their buy-in for successful policy and practice guidelines development and implementation, augmenting successful outcomes. Healthcare professionals such as physicians and nurses provide practical insights about patients’ needs and preferences, ensuring the concept of patient-centeredness is included during policy development (Persson et al., 2021). Finally, the quality assurance team’s participation is vital to monitor compliance with the policy and practice guidelines within the organization. Overall, the active participation of these stakeholders generates more robust policy and practice guidelines, promoting its successful and sustainable execution.

Strategies for Collaborating with  Stakeholders

The stakeholder group plays a pivotal role in implementing the proposed guidelines for foot examinations in diabetic patients. The collaboration of these stakeholders is vital for improving clinical outcomes and a successful policymaking process (Balane et al., 2020). Establishing a culture of consistent group meetings will foster open communication and address stakeholders’ concerns, promoting collaboration. Another effective strategy to foster collaboration is interprofessional education (IPE). This training encourages team members to connect and motivates shared decision-making.

Lastly, creating a feedback mechanism allows stakeholders to share experiences and address challenges, nurturing a sense of shared responsibility. Overall, this collaboration is imperative to overcome potential resistance among stakeholders, ensuring a comprehensive and effective development and implementation of the proposed policy and practice guidelines.


ADA. (n.d.). The American Diabetes Association Comprehensive Diabetic Foot Exam Guidelines | American Diabetes Association. Professional.diabetes.org. https://professional.diabetes.org/webcast/american-diabetes-association-comprehensive-diabetic-foot-exam-guidelines-0 

Balane, M. A., Palafox, B., Palileo-Villanueva, L. M., McKee, M., & Balabanova, D. (2020). Enhancing the use of stakeholder analysis for policy implementation research: Towards a novel framing and operationalised measures. BMJ Global Health5(11), e002661. https://doi.org/10.1136/bmjgh-2020-002661 

Basil, N. N., Ambe, S., Ekhator, C., & Fonkem, E. (2022). Health records database and inherent security concerns: A review of the literature. Cureus14(10), e30168. https://doi.org/10.7759/cureus.30168 

Carmichael, J., Fadavi, H., Ishibashi, F., Shore, A. C., & Tavakoli, M. (2021). Advances in screening, early diagnosis and accurate staging of diabetic neuropathy. Frontiers in Endocrinology12, 671257. https://doi.org/10.3389/fendo.2021.671257 

NHS FPX 6004 Assessment 2 Policy Proposal

CMS. (n.d.). Background: The Affordable Care Act’s new rules on preventive care. https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/preventive-care-background 

CMS (n.d.). Diabetes: Foot Exam. Qpp.cms.gov. https://qpp.cms.gov/docs/ecqm-specs/2017/EC_CMS123v5_NQF0056_Diab_Foot/CMS123v5.html#:~:text=The%20foot%20examination%20should%20include 

CMS. (2023, June). Hospital Readmissions Reduction Program (HRRP) | Www.cms.gov. https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp 

Gomez, L. E., & Bernet, P. (2019). Diversity improves performance and outcomes. Journal of the National Medical Association111(4), 383–392. https://doi.org/10.1016/j.jnma.2019.01.006 

Guy, L. (2022). Increasing appointment adherence in patients with diabetes mellitus via appointment reminders and patient education. University of St. Augustine for Health Scienceshttps://doi.org/10.46409/sr.rhku8033 

Hussein, M., Pavlova, M., Ghalwash, M., & Groot, W. (2021). The impact of hospital accreditation on the quality of healthcare: A systematic literature review. BMC Health Services Research21(1), 1057. https://doi.org/10.1186/s12913-021-07097-6 

Lessing, S. E., & Hayman, L. L. (2019). Diabetes care and management using electronic medical records: A systematic review. Journal of Diabetes Science and Technology13(4), 774–782. https://doi.org/10.1177/1932296818815507 

NHS FPX 6004 Assessment 2 Policy Proposal

Moucheraud, C., Lenz, C., Latkovic, M., & Wirtz, V. J. (2019). The costs of diabetes treatment in low- and middle-income countries: A systematic review. BMJ Global Health4(1), e001258. https://doi.org/10.1136/bmjgh-2018-001258 

Nduati, J. N., Gatimu, S. M., & Kombe, Y. (2022). Diabetic foot risk assessment among patients with type 2 diabetes in Kenya. The East African Health Research Journal6(2), 196–202. https://doi.org/10.24248/eahrj.v6i2.698 

Persson, M. H., Mogensen, C. B., Søndergaard, J., Skjøt-Arkil, H., & Andersen, P. T. (2021). Healthcare professionals’ practice and interactions in older peoples’ cross-sectoral clinical care trajectories when acutely hospitalized—A qualitative observation study. BMC Health Services Research21(1), 944. https://doi.org/10.1186/s12913-021-06953-9  


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