NURS FPX 6004 Assessment 2 Policy Proposal

NURS FPX 6004 Assessment 2 Policy Proposal

Name: Capella University
Instructor’s name
October 2023

Policy Proposal

Healthcare organizations are continually challenged to enhance the quality of care provided to patients. This assessment focuses on addressing a significant shortcoming in benchmark performance at Mercy Medical Center, specifically related to the underperformance of foot exams for diabetic patients. The assessment aims to develop a comprehensive policy proposal and practice guidelines to rectify this issue, ensuring better patient outcomes and compliance with healthcare regulations. This proposal leverages ethical principles, evidence-based practices, and stakeholder engagement to create a holistic approach to improving diabetic care at Mercy Medical Center, setting the stage for transformative change in healthcare delivery.

Police and Practice Guidelines addressing Benchmark Underperformance

Creating a policy and practice guidelines to address a shortfall in meeting a benchmark metric prescribed by local, state, or federal healthcare policies or laws is imperative due to its far-reaching implications. When benchmarks are not met, it signifies a failure to comply with established standards, potentially resulting in compromised patient care, legal ramifications, and damage to the organization’s reputation. In the context of Mercy Medical Center’s underperformance in foot exams, the need for a targeted policy is underscored by the potential consequences of inaction. Failure to meet benchmark metrics for foot exams may lead to delayed detection and intervention for diabetes-related complications, ultimately negatively impacting patient outcomes. Foot complications can escalate to severe conditions, including amputations, which not only have severe physical and psychological consequences for patients but also impose significant healthcare costs. It is essential to recognize that the failure to address benchmark underperformance can result in detrimental effects on patients’ health, exacerbating healthcare expenditure, and contributing to patient dissatisfaction. 

Inaction regarding benchmark underperformance can have significant repercussions for Mercy Medical Center and its stakeholders. Notably, non-compliance with healthcare regulations and benchmarks may invite scrutiny from regulatory bodies, leading to potential legal consequences and financial penalties for the organization (Mogakwe et al., 2020). This can divert resources away from essential healthcare operations and quality improvement initiatives, further straining the healthcare system’s resources. Additionally, it may erode the trust and confidence of patients in the organization, potentially driving them to seek healthcare services from other providers. Consequently, the organization may experience a decline in patient retention and a reduction in revenue. The potential financial and legal repercussions can also impede the organization’s long-term sustainability and growth. The need for policy and practice guidelines is evident in their capacity to mitigate these consequences, ensuring compliance with benchmarks, maintaining high-quality care, and safeguarding the organization’s reputation and financial viability (Mogakwe et al., 2020). Effective policies in this context must address the root causes of underperformance, set clear expectations for compliance, and provide mechanisms for ongoing monitoring and improvement.

Addressing benchmark underperformance not only aligns with ethical principles but also fosters a culture of patient-centered care and continuous improvement (Varkey, 2021). The principle of beneficence emphasizes the organization’s moral duty to act in the best interests of patients, advocating for early detection and intervention to prevent harm. It recognizes the organization’s obligation to deliver the highest quality of care, improve patient outcomes, and enhance the overall well-being of patients. Ethical considerations guide the organization in fulfilling its duty of care and upholding the principles of patient autonomy, respect, and dignity. Policies aimed at improving benchmark performance, in this case, foot exams, ensure that patients have access to essential preventive measures, enabling them to make informed decisions about their healthcare. Furthermore, sustainable actions linked to the policy can establish a culture of continuous improvement that transcends immediate interventions, ensuring that the organization consistently delivers high-quality care and complies with healthcare regulations. By addressing the shortfall in meeting benchmark metrics, the organization not only fulfills its ethical obligations but also aligns with sustainability goals that prioritize long-term excellence and the best interests of patients and stakeholders (Varkey, 2021).

Organizational Policy or Practice Change Guideline

The proposed organizational policy for Mercy Medical Center aims to address the underperformance in foot exams, a benchmark metric associated with diabetes care. This policy outlines the establishment of standardized protocols for foot exams to ensure that all diabetic patients receive timely and comprehensive assessments. It further emphasizes the importance of training and education programs for healthcare professionals to equip them with the necessary skills and knowledge to perform accurate foot examinations. Additionally, the policy includes provisions for continuous performance monitoring, ensuring that healthcare providers adhere to the established guidelines. The practice guidelines within this policy stipulate that healthcare professionals should conduct a foot exam during each diabetic patient’s regular check-up, with a focus on early detection and intervention for foot-related complications. The guidelines stress the ethical principles of beneficence and autonomy, empowering patients to make informed decisions about their healthcare while providing comprehensive preventive measures (J Patrick Vaughan et al., 2021).

Environmental factors play a crucial role in influencing the recommended practice guidelines outlined in this policy. Firstly, the organization’s resource availability, including staffing and equipment, impacts the feasibility of conducting regular foot exams. Inadequate resources may hinder the implementation of the guidelines, emphasizing the need for resource allocation to support the recommended practices. Secondly, the organization’s culture and existing workflows may influence healthcare professionals’ willingness and capacity to adhere to the guidelines (Correa et al., 2020). A culture that prioritizes patient-centered care and continuous improvement is more likely to foster compliance with the recommendations. Conversely, resistance to change or outdated practices may impede the integration of new guidelines. Thirdly, external factors such as regulatory requirements and guidelines from healthcare governing bodies can significantly affect the organization’s approach to implementing the policy (Correa et al., 2020). Compliance with external regulations may necessitate policy adjustments to align with the broader healthcare environment.

Evidence-Based Practice Guidelines to Improve Targeted Benchmark

To improve the targeted benchmark performance of foot exams, Mercy Medical Center must implement a set of ethical, evidence-based practice guidelines. These guidelines should emphasize the early and regular assessment of diabetic patients’ feet to detect potential complications promptly. Healthcare providers must conduct comprehensive foot exams during each patient’s regular check-up, as early detection is essential for preventing severe complications, such as amputations (Tathare et al., 2023). These guidelines align with ethical principles, particularly beneficence and autonomy, as they prioritize patient well-being and provide patients with the information and preventive measures, they need to make informed healthcare decision. Moreover, they are rooted in credible evidence, as studies have shown that regular foot exams are effective in reducing the incidence of foot-related complications among diabetic patients (Tathare et al., 2023). Therefore, these practice guidelines are not only ethical but also evidence-based, with a clear focus on enhancing patient outcomes and well-being.

The impact of these practice guidelines on stakeholders is significant. First and foremost, patients stand to benefit from improved diabetic care, as they will receive regular foot exams that can prevent severe complications, enhance their quality of life, and potentially save them from amputations. Healthcare providers, including physicians and nurses, may experience an initial adjustment period as they adapt to the new guidelines and workflow. However, these changes will lead to a deeper commitment to patient-centered care and compliance with ethical principles, aligning with their professional values. The organization will see improvements in patient satisfaction, as patients are more likely to trust an organization that prioritizes their well-being and empowers them with knowledge about their healthcare (Tathare et al., 2023). 

Involvement of Stakeholders in Development and Implementation of Policy

The development and implementation of the proposed policy and practice guidelines for improving foot exams in diabetic care at Mercy Medical Center necessitate the involvement of specific stakeholders and groups. Foremost, the engagement of healthcare professionals, including physicians, nurses, and clinical staff, is essential. These front-line healthcare providers directly interact with patients, conduct foot exams, and play a pivotal role in implementing the new guidelines. Their engagement is vital to ensure their understanding, commitment, and adherence to the recommended practices, fostering a culture of patient-centered care. Involving them in the development phase allows their insights, concerns, and expertise to be incorporated into the policy, making it more practical and relevant to the daily clinical workflow (McKevitt et al., 2020).

Patient engagement is equally crucial. Diabetic patients are the primary beneficiaries of the policy and practice guidelines. Involving them in the development process through feedback, education, and empowerment is key to respecting the ethical principle of autonomy and ensuring that the guidelines align with their healthcare preferences and needs (McKevitt et al., 2020). Patients’ active involvement in the policy development facilitates a more patient-centric approach and enhances patient buy-in, leading to improved compliance with the guidelines. 

Strategies for Collaboration with Stakeholders

Collaborating with stakeholder groups is pivotal for the successful implementation of the proposed policy and practice guidelines for improving diabetic care at Mercy Medical Center. Engaging healthcare professionals, patients, and other relevant stakeholders in the process is not only ethical but also enhances the likelihood of policy acceptance and adherence. To facilitate this collaboration, a multi-pronged approach should be adopted (Poger et al., 2019). Regular meetings and workshops involving healthcare providers can be conducted to explain the policy’s rationale, expected benefits, and to gather their feedback and suggestions. By involving healthcare professionals in the development phase and addressing their concerns, their objections can be addressed proactively, fostering a sense of ownership and commitment to the policy (Poger et al., 2019).

Patient engagement can be achieved through educational campaigns, informational materials, and focus group discussions. By clearly articulating the benefits of the proposed practice guidelines, patients can better understand how these changes will improve their care and health outcomes. Addressing potential objections from patients, such as concerns about disruptions to their routines or changes in care procedures, can help alleviate apprehensions and secure their buy-in. In essence, this collaborative approach acknowledges and respects the perspectives of different stakeholders, considers their objections, and provides clear explanations to build consensus and foster a shared commitment to implementing the policy and practice guidelines (Poger et al., 2019). By involving and educating all relevant stakeholders, Mercy Medical Center can ensure a smoother transition to the new guidelines and enhance the quality of care for diabetic patients.


The proposed policy and practice guidelines for improving diabetic care at Mercy Medical Center present a well-rounded strategy that embraces ethical principles, evidence-based practices, and stakeholder engagement to enhance patient outcomes and healthcare quality. These guidelines prioritize early detection and intervention for foot complications, aligning with the principles of beneficence and autonomy, while also offering the potential for cost savings and long-term sustainability. By involving healthcare professionals and patients in the development process, the policy not only gains credibility but also fosters a culture of patient-centered care. Through collaboration and a shared commitment to change, Mercy Medical Center can move closer to achieving the highest standards in healthcare delivery, ensuring improved patient outcomes and a sustainable future in an ever-evolving healthcare landscape.


Correa, V. C., Lugo-Agudelo, L. H., Aguirre-Acevedo, D. C., Contreras, J. A. P., Borrero, A. M. P., Patiño-Lugo, D. F., & Valencia, D. A. C. (2020). Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: A systematic metareview. Health Research Policy and Systems, 18(1). https://doi.org/10.1186/s12961-020-00588-8 

J Patrick Vaughan, Victora, C. G., & Chowdhury, R. (2021). Using ethical principles. Oxford University Press EBooks, 213–221. https://doi.org/10.1093/med/9780192848741.003.0016 

McKevitt, C., Fudge, N., & Pinel, C. (2020). Involving patients and publics in healthcare. Healthcare Public Health, 33–45. https://doi.org/10.1093/oso/9780198837206.003.0004 

Mogakwe, L. J., Ally, H., & Magobe, N. B. D. (2020). Reasons for non-compliance with quality standards at primary healthcare clinics in Ekurhuleni, South Africa. African Journal of Primary Health Care & Family Medicine, 12(1). https://doi.org/10.4102/phcfm.v12i1.2179 

Poger, J. M., Yeh, H.-C., Bryce, C. L., Carroll, J. K., Kong, L., Francis, E. B., & Kraschnewski, J. L. (2019). Path to partnership in stakeholder-engaged research: A framework for stakeholder engagement in the Path to Health Diabetes study. Healthcare, 8(1). https://doi.org/10.1016/j.hjdsi.2019.05.001 

Tathare, S. R., Kumbhar, V. N., Panse, R. J., Kumaran, S., Deshmukh, S., & Bidaye, A. (2023). Examination of feet in people with diabetes: A guide for primary care physicians. Chronicle of Diabetes Research and Practice, 2(2), 90. https://doi.org/10.4103/cdrp.cdrp_11_22 

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

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