Health Care Law and Policy-Policy Proposal

Healthcare leaders evaluate their workplace performances to initiate change. Often, problems in healthcare range from patient and environment to provider-related issues. Leaders initiate change through policy making/ development or policy improvement. These policies require extensive research of evidence-based and best practices, including benchmarking with other institutions to manage the existing problem in the healthcare institution.

Health Care Law and Policy-Policy Proposal

Leaders also leverage policies and laws at the local, state, and federal levels to make decisions that do not positively impact care delivery. This essay focuses on policy and practice guidelines proposal to address Mercy Medical Center’s shortfalls in diabetes follow-up and management metrics.

The Need for Creating Policy and Practice Guidelines

The benchmark evaluation results created the need and urgency for policy changes. An evaluation of the public diabetes dashboard showed significant gaps in diabetes follow-up and management. The government, through the agency for healthcare quality and research, recommends biannual HbA1c tests for proper diabetes monitoring.

Mercy medical center statistics show that the number of individuals who had an HbA1c test is relatively few. Missing parts of information, such as the total number of diabetes patients and the patients who went for two visits, makes it difficult to make accurate calculations. Using statistics from the last quarter, less than 20% of diabetic patients attended the HbA1c tests, compared to the recommended coverage of 79.5% by the AHRQ in the NHDQR (NHDQR, 2021).

The data availability gaps in Mercy Medical Center are a great undoing. Lack of data in a healthcare institution prevents quality improvement initiatives or the need to improve healthcare service delivery. It also masks problems and further compromises care. It prevents the healthcare leadership from effective daily functioning, such as resource allocation and delegation practices, and the institution should promptly address the problem.

The low HbA1c results indicate poor management and should be promptly addressed. Low HbA1c testing is an indication of poor diabetes management. Campbell et al. (2019) state that HbA1c tests the variations in blood sugar management and the effectiveness of interventions. HbA1c tests allow healthcare providers to predict problems such as ineffectiveness of therapy, non-adherence to medications, and underlying pathologies preventing individuals from adequately regulating their blood sugar despite taking medications as prescribed (Campbell et al., 2019).

Complications such as diabetic foot, stroke, blindness, and peripheral neuropathies all arise from poorly controlled diabetes. More than 90% of diabetes patients who develop diabetic complications begin with poorly controlled diabetes (Imai et al., 2021). Thus, measuring the HbA1c levels is integral in determining therapy effectiveness and implementing change interventions.

Individuals with poorly controlled diabetes (HbA1c>7%) are marked as high-risk and proper interventions that include lab workups for underlying pathologies that could be negatively affecting diabetes management (Imai et al., 2021). HbA1c tests are thus integral during patient management and monitoring, and their underperformance is thus an issue of great interest.

Ethical, Evidence-based Practice Guidelines

Staff and patient education are the best interventions to solve the underperforming benchmark. Staff education will increase their knowledge and will also influence the knowledge they impact on patients and their families. Understaffing is one of the problems affecting Mercy Medical Center. Training them might have little effect on the patient education they deliver, considering their already high burden of patient management.

However, the ethical, evidence-based intervention is extensively planned and executed in patient education by experienced and reputable healthcare personnel. Ghisi et al. (2021) note that patient education increases the perceived benefits of follow-up, patient initiative, and personal directives, which help initiate change and promote adherence to the change.

The hospital prepares its reports every three months (quarterly). The number of new patients and many other statistics are done quarterly. Patients at the beginning of their management journey are more attentive and participative; thus, it is the best time to educate them (). The education program will be two education sessions in every quartet, mandatory for all newly diagnosed patients. The education sessions will focus on teaching patients the importance of HbA1c testing, the benefits, and the risks associated with failure to take these tests, as supported by Imai et al. (2021).

The outpatient diabetes clinic has ample space where all patients can be educated before receiving other healthcare services. Barriers to healthcare services access and utilization include physical (distance), social (lack of knowledge), and cultural factors (negative views about hospitals, stereotypes, rituals, and norms) (Olson et al., 2021). Patient education tackles most social and cultural factors to increase patients’ access to healthcare resources.

Thus, increasing their knowledge at the beginning of their treatment promotes action and adherence and prevents misinformation in society from occurring when the correct information is not delivered.

Effects of Environmental Factors on the Proposed Policy Guidelines

Policies, laws, and acts shape healthcare decisions, define their scope, and empower or limit them. These laws affect various aspects of quality improvements that include effects on patients and other stakeholders, healthcare technology utilization, and data sharing. The agency for healthcare research and quality is responsible for ensuring quality improvement projects’ success in healthcare institutions.

The agency stipulates that healthcare institutions must use patient-friendly technology (considering age, healthcare condition, need, costs, the usability of technology, and ability to learn) to educate patients (AHRQ, n.d.). When educating the patients, using audio-visual communication with simplified language and less content will ensure patients understand what they are taught. Cultural sensitivity is also an important aspect of patient education, and utilizing healthcare professionals from the same or similar community will help ensure cultural sensitivity.

AHRQ’s universal Literature Precautions Toolkit equips professionals with the knowledge and skills to communicate effectively with all patients. The toolkit recommends adequate interaction and follow-up; hence, the program should have an extended follow-up program to help track changes and prove the effectiveness of the programs in meeting the underperforming benchmark.

It also entails the AHRQ train-the-trainer program, which will help train healthcare professionals before training patients. The training will orient them to the purpose and objectives, increasing their precision and success in meeting them, hence the project’s success (AHRQ, n.d.).

The HIPAA act regulates healthcare data access and sharing. The act protects confidential patient information, and its use in various healthcare institutions, by ensuring that sensitive patient information is inaccessible to unauthorized persons (, n.d.). The patient education program will not use patient data for purposes other than the consent form.

Only professionals involved in the program’s running will be allowed to access the information to protect patients and promote confidentiality. They will be given personalized passwords for accountability purposes. Ensuring patient confidentiality will increase patients’ participation in the program. The AHQR and HIPAA acts will therefore be important considerations for the success of the proposed program.

Proposed Policy and Practice Guidelines Challenges

One of the significant challenges to implementing the proposed policy guidelines is inadequate financing. Preparation and running of the program will require a considerable amount of money. Since the teach-the-trainer program is meant to improve nurses’ knowledge, education, and follow-ups, the use of technology in the program is costly.

The program may require external funding. More so, some patient education programs require specific professional specialists who may be costly to pay. The program implementation also requires adequate data collection and analysis, which is costly. Therefore, proper resource planning and management is a requirement for the success of the implementation of the proposed policy guidelines.

Stakeholders for the Policy and Practice Guidelines Proposal

The stakeholders are integral in ensuring the acceptability and successful implementation. Proactively selecting the stakeholders of a policy and practice guidelines prevents the development of poor policies, which could most likely get rejected. The implementation of the proposed policy will require several stakeholders. The stakeholders include state and federal leaders, healthcare professionals, diabetic patients, and their families, and healthcare institution leaders. These stakeholders will ensure the effectiveness and applicability of the proposed guidelines.

The most important stakeholder in the program implementation is the diabetic patients and their families. Putting the patients at the center of the policy and practice implementation will ensure that their needs are adequately addressed.

Patient-centered interventions improve the implementation and applicability of a policy. Patient perspectives can help change interventions to maintain relevance and effectiveness. Healthcare conditions affect patients differently, and their barriers to accessing healthcare services could vary. These include cultural barriers and poor perceived benefits (Ghisi et al., 2021).

Healthcare professionals interact with the patients the most, and they can collect data to help understand the patients’ needs, thus improving the policy guidelines. The healthcare institution leaders validate the data, promoting the acceptability of the policy guidelines. The state and federal leaders provide information on diabetic patient education to the regulatory agencies, leading to higher chances of the proposed policy’s success.

Fareed and Su (2021) emphasize the role of healthcare leaders as stakeholders in providing feedback and availing data for quality decision-making; hence they affect the quality of policy and practice guidelines. The involvement of all stakeholders in implementing the proposed policy and practice guidelines is integral in ensuring strong policies that are easily accepted and implemented successfully.


Healthcare improvement programs are based on best practices from evidence-based literature. Patient education to diabetic patients can improve diabetes management by enhancing help-seeking behavior and influencing patients’ accountability. Policy and practice guidelines are proposed to the existing guidelines to ensure improvement in diabetic foot examinations.

The existing state and federal regulations should be considered when handling quality improvement programs. Compliance with the guidelines ensures high-quality, ethical, and acceptable policy interventions. Stakeholders and stakeholder groups should be identified proactively. The stakeholder needs and concerns should be considered for the acceptability and successful implementation of the proposed policy and practice guidelines.


  • Agency for Healthcare Quality ad Research (AHQR) (n.d.). Patient Engagement and Education. Accessed 3rd July 2022 from
  • Agency for Healthcare Quality and Research (AHQR) (n.d.). Health Information Technology (HIT). Accessed 3rd July 2022, from
  • Campbell, L., Pepper, T., & Shipman, K. (2019). HbA1c: a review of non-glycemic variables. Journal of Clinical Pathology, 72(1), 12-19.
  • Catania, V., Greenberg, G., & Bren, D. (2018). Putting Your Foot Down: Improving Diabetic Foot Exam Rates. Leigh Valley Health Network Scholalry Works.
  • Fareed, M. Z., & Su, Q. (2021). Transformational leadership and project success: A mediating role of public service motivation. Administration & Society, 00953997211040466.
  • Ghisi, G. L. D. M., Seixas, M. B., Pereira, D. S., Cisneros, L. L., Ezequiel, D. G. A., Aultman, C., Sandison, N., Oh, P., & da Silva, L. P. (2021). Patient education program for Brazilians living with diabetes and prediabetes: findings from a development study. BMC Public Health, 21(1), 1-16.
  • Health Information Privacy (n.d.). The HIPAA Privacy Rule. US department of health and human services (HHS), Office of Civil Rights (OCR). Accessed 4th July 4, 2022, from
  • Imai, C., Li, L., Hardie, R. A., & Georgiou, A. (2021). Adherence to guideline-recommended HbA1c testing frequency and better outcomes in patients with type 2 diabetes: a 5-year retrospective cohort study in Australian general practice. BMJ Quality & Safety30(9), 706-714.
  • Olson, R. E., Mutch, A., Fitzgerald, L., & Hickey, S. (2021). The social and cultural determinants of health. Culture, Diversity, and Health in Australia (pp. 15-35). (1st ED.). Routledge.

Health Care Law and Policy-Policy Proposal Instructions

Assessment 2 Instructions: Policy Proposal

Top of Form

Bottom of Form

  • 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 to bring to discussions about 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 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?
    • Recommend ethical, evidence-based practice guidelines to improve targeted benchmark performance prescribed by applicable local, state, or federal health care policy or law.
      • 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 would you propose to apply these strategies in the context of Eagle Creek Hospital or your own practice setting?
      • How can you ensure these strategies are ethical and culturally inclusive in their application?
    • 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 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?
    • 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.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:

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.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

    • Competency 1: Analyze relevant health care laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
      • Analyze the potential effects of environmental factors on recommended practice guidelines.
    • Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
      • Recommend ethical, evidence-based practice guidelines to improve targeted benchmark performance prescribed by applicable local, state, or federal health care policies or laws.
    • Competency 3: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, to inform health care laws and policies for patients, organizations, and populations.
      • Explain the need for creating a policy to address a shortfall in meeting a benchmark metric prescribed by local, state, or federal health care policies or laws.
    • Competency 4: Develop strategies to work collaboratively with policy makers, stakeholders, and colleagues to address environmental (governmental and regulatory) forces.
      • Explain why particular stakeholders and groups must be involved in further development and implementation of a proposed policy and practice guidelines.
    • Competency 5: Produce clear, coherent, and professional written work, in accordance with Capella’s writing standards.
      • Organize content so ideas flow logically with smooth transitions.
      • Use paraphrasing and summarization to represent ideas from external sources.