policy proposal

Write a 4-6 page policy proposal and practice guidelines for improving quality and performance associated with the benchmark metric underperformance you advocated for improving in Assessment 1.


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 guideline proposals that will enable a team, a unit, or an 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.

As a master’s-level health care practitioner, you have a valuable viewpoint and voice on policy development, both inside and outside your care setting. Developing policy for internal purposes can be a valuable process toward quality and safety improvement, as well as ensuring compliance with various health care regulatory pressures. This assessment offers you an opportunity to take the lead in proposing such changes.


Propose an organizational policy and practice guidelines that you believe will lead to an improvement in quality and performance associated with the benchmark underperformance you advocated for improving in Assessment 1. Be precise, professional, and persuasive in demonstrating the merit of your proposed actions.


The policy proposal 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.

  • Explain the need for creating a policy and practice guidelines to address a shortfall in meeting a benchmark metric prescribed by local, state, or federal health care policies or laws.
    • What is the current benchmark for the organization and the numeric score for the underperformance?
    • How is the benchmark underperformance potentially affecting the provision of quality care or the operations of the organization?
    • What are the potential repercussions of not making any changes?
      • What evidence supports your conclusions?
  • Summarize your proposed organizational policy and practice guidelines.
    • Identify applicable local, state, or federal health care policy or law that prescribes relevant performance benchmarks that your policy proposal addresses.
    • Keep your audience in mind when creating this summary.
  • Analyze the potential effects of environmental factors on your recommended practice guidelines.
    • What regulatory considerations could affect your recommended guidelines?
    • What resources could affect your recommended guidelines (staffing, financial, and logistical considerations, or support services)?
  • Explain ethical, evidence-based practice guidelines to improve targeted benchmark performance and the impact the proposed changes will have on the targeted group.
    • What does the evidence-based literature suggest are potential strategies to improve performance for your targeted benchmark?
    • How would these strategies ensure performance improvement or compliance with applicable local, state, or federal health care policy or law?
    • How can you ensure that these strategies are ethical and culturally inclusive in their application?
    • What is the direct impact of these changes on the stakeholders’ work setting and job requirements?
  • Explain why particular stakeholders and groups must be involved in further development and implementation of your proposed policy and practice guidelines.
    • Why is it important to engage these stakeholders and groups?
    • How can their participation produce a stronger policy and facilitate its implementation?
  • Present strategies for collaborating with the stakeholder group to implement your proposed policy and practice guidelines.
    • What role will the stakeholder group play in implementing your proposal?
    • Why is the stakeholder group and their collaboration important for successful implementation?
  • Organize content so ideas flow logically with smooth transitions.
    • Proofread your proposal, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your proposal.
  • Use paraphrasing and summarization to represent ideas from external sources.
    • Be sure to apply correct APA formatting to source citations and references.
Policy Proposal Format and Length

It may be helpful to use a template or format for your proposal that is used in your current organization. The 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 organization does not have these resources, many appropriate templates are freely available on the Internet.

Your policy should be succinct (about one paragraph). Overall, your proposal should be 4–6 pages in length.

Supporting Evidence

Cite 3–5 references to relevant research, case studies, or best practices to support your analysis and recommendations.


Miatta Teasley

Capella University



April 19,2022




Second Quarter Hypertension Intervention Compliance at Med for adults presenting with Diabetes
Intervention Needed Completed Compliance Percentage
Initial Lactate within 3 hours 30 30 100%
Blood cultures were drawn before antibiotics 22 17 77%
Antibiotics administered within 3 hours 22 20 91%
Fluid resuscitation if in septic shock within 2hours 19 12 63%
Vasopressors if hypertension persists after fluid or lactate >4mmoL/L within 6 hours 12 7 58%
Overall 105 86 82%



Second Quarter Dialysis Intervention
Compliance and Inpatient Mortality
Patient ID Number of Interventions needed Number of Interventions completed Inpatient Mortality
2000 4 2 0
2014 3 3 1
2098 2 1 0
2134 5 4 0
2156 3 4 1
2245 4 2 0
2345 3 3 1
2567 5 4 1
2676 4 1 1
2935 3 2 0
Note: The Staffing benchmark for the nurse staffing unit is 3 patients per nurse. The average monthly staffing for the unit is 3 nurse workloads. The average number of patients in the unit per month in the third quarter was 5.75.




The data above is a review regarding the compliance of Dialysis measures and interventions compliance and the sample of the second quarter inpatient mortality. The information below entails evaluating the data, which indicates that various departments need to be improved, and a proposal for a specific area and target for improvement.

Evaluation of Dashboard Metrics

There are several inefficiencies in regards to dialysis measures at Med. From the dashboard concerning the compliance of executing the arranged measures and procedures, the two stand out at the 77% compliance rate on drawing blood cultures before running antibiotics and 58% compliance rate on administering vasopressors for those patients that require them. As per Medicare.Gov (n.d), the national average for meeting dialysis guidelines is 72%, and the state of Minnesota is 60% which indicates that Med is performing at 82% overall testing. Higher percentages are required to ensure the advanced quality of life for residents of the healthcare institution (Morfín et al., 2018).

Failure to complete blood draws for cultures before running broad-spectrum antibiotics; there will be an incapability to authorize contamination and the responsible pathogen. This can result in an inefficient or ineffective intervention for aiding a patient. Moreover, by failing to confirm infection from the start, unnecessary and wasteful care interventions could be performed or ordered for patients (Morfín et al., 2018). As per the failure to administer vasopressors, the institution is gambling with the patient’s life. As the reinforcement for the dialysis unit states, vasopressor therapy is needed to sustain and uphold perfusion in the wake of life-threatening hypertension. The needed nature of compliance concerning administering this intervention can be seen in the sample of data concerning compliance and inpatient mortality. As per the four patients needing vasopressors, they received three, and one did not. The one that did not die. A study of data from patients from 2014 to 2017 indicated that the inhouse mortality ranges from 14.7% to 29.9%. Based on the information above, Med has a 42% mortality rate which is intolerable.

Analysis of challenges in attaining satisfactory performance

There are two chief challenges facing the institution, and the patient care department is liable for the care of adult patients with Diabetes. The first issue is that the Department is understaffed across the period. In a monthly average patient number, the Department was understaffed by 1.34 nurse workload departments. This is difficult because involvement may not have been achieved because of the lack of suitable employment. Moreover, from the compliance unit’s perspective, the institution has not been employing the required standard for the Department. Healthcare personnel working in all units should have HIPAA certificates that indicate that they are competent enough to handle dialysis units and give proper dose. There are issues when it comes to employing qualified and competent staff, including financial burden and logistics (Rizzolo, Novick & Cervantes, 2020). Nonetheless, it happens that additional staffing is needed for the care unit. This results in the divergement of patients to other facilities, which can result in huge financial constraints, as evidenced in the facility.

The other challenge is the potential cause of dialysis intervention that is not being administered in the right way, which is that Med does not have a formal policy or practice rules for any of the care at any level in the institution. The National Chronic Kidney Disease Benchmark indicates that patients with kidney disease should at least have 3 haemodialysis in a week. Each session should last for three to five hours. There is a memorandum that the institution for critical care medicine has produced the definitive guidelines for practice around treating adult diabetes. Nonetheless, there are no procedures regarding how personnel in Med should be applying these resources to their practice. Guidelines to safeguard the ordering required for tests should be developed and reinforced (Rizzolo, Novick & Cervantes, 2020).

Areas of Improvement

Looking into the data in the dashboards, the institutions must design a plan within the recommended interventions for dialysis that are presently tracked, which will offer the best result for administering vasopressors and blood culture. This recommendation is from the perspective of the patient as well as ethical care. Fifty percent mortality rate in patients in the second quarter of dialysis sample did not receive the needed intervention, which is intolerable. As a result, guidelines should be put in place to ensure patient care. Designing a training program is essential to introduce nurses and doctors to the practice guidelines to address the matter. The tactic is also needed to concentrate on the necessities of compliance with undertaking all important interventions from the perspective of the patient’s safety (Erickson & Winkelmayer, 2018).

The accumulation of automated protocols could aid in ensuring that there are timely responses to meet the tests needed when undertaking dialysis in patients. The institution should involve key stakeholders, including ordering providers, nurses, laboratory personnel, and the Department of technology and information. Each unit is required to safeguard the timely ordering and completion of the essential testing for dialysis. Admittedly, the tactic does not address the shortage of nurse personnel (Crews & Novick, 2020). Nonetheless, by formalizing training and education of the personnel that the institution does have automated systems, it is hoped that the institution will mitigate some of the challenges in staffing. At the same time, a recommendation in the human resource department and finance department are met.

Thank you for reading through the report. I hope that all the queries needed to be looked into have been answered in the paper. If any information has not been addressed, kindly inform me through my email or make an appointment in my office. I would be interested in aiding you in shaping the direction that will develop the policy and practice guidelines to ensure efficient and effective patient care for dialysis patients.


Crews, D. C., & Novick, T. K. (2020, January). Achieving equity in dialysis care and outcomes: the role of policies. In  Seminars in dialysis (Vol. 33, No. 1, pp. 43-51).

Erickson, K. F., & Winkelmayer, W. C. (2018). Evaluating the evidence behind policy mandates in US dialysis care.  Journal of the American Society of Nephrology,  29(12), 2777-2779.

Medicare.Gov (n.d.) Hospital Compare. Timely and Effective Care. dialysis Care. Minneapolis MN. https://www.medicare.gov/hospitalcompare/compare.html#cmprTab=2&cmp rID=240080%2C240053&cmprDist=2.3%2C7.9&dist=25&loc=MINNEAPOLI S%2C%20MN&lat=44.983334&lng=-93.26667

Morfín, J. A., Yang, A., Wang, E., & Schiller, B. (2018, January). Transitional dialysis care units: a new approach to increase home dialysis modality uptake and patient outcomes. In  Seminars in Dialysis (Vol. 31, No. 1, pp. 82-87).

Rizzolo, K., Novick, T. K., & Cervantes, L. (2020). Dialysis care for undocumented immigrants with kidney failure in the COVID-19 era: public health implications and policy recommendations.  American Journal of Kidney Diseases,  76(2), 255-257.

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