NHS-FP6004 Assessment 2 Policy Proposal Essay

NHS-FP6004 Assessment 2 Policy Proposal Essay

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.

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.

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 Instructions for NHS-FP6004 Assessment 2 Policy Proposal

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.

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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.


PROPOSAL REQUIREMENTS for NHS-FP6004 Assessment 2 Policy Proposal

Note: The tasks outlined below correspond to grading criteria in the scoring guide.

In your proposal, senior leaders have asked that you:

  • 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.
  • 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.

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.

Organizational Ethics Decision-Making Process in Health Care.

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.

    • Whitlock, R. (2016, April 15). United States: Talking about the challenge of quality in health care policy development. Mondaq Business Briefing.


NHS-FP6004 Assessment 2 Policy Proposal Example

Statistics show there are preventable measures to reduce falls and avoid them from reoccurring. Typically, 700,000 and 1 million patients fall in hospitals yearly, as stated by the Agency for Healthcare Research and Quality.

Data reports show that many of the patients who fail are not seriously hurt, however, fall rate injuries are substantial. The Joint Commission data shows an average growth in a hospital’s overhead costs for an injury that is fall-related costs the hospital more than $13,000, and the patient’s time spent increases by an average of 6.27 days.

Also, research shows that between 30 and 51 percent of falls result in an injury. (Butcher, 2017) Mercy Medical dashboard metrics data showed an increase in falls and documentation errors due to the mistakes of employees in the years 2015 and 2016.

Many factors can lead to high fall rates, such as poor communication between staff, incorrect documentation, and poor nurse assessments. This policy proposal should be considered to decrease the number of falls and prevent the possibility of falls from occurring. Furthermore, this will increase overall performance, the likelihood of meeting targets, and effective patient care delivery.

Ethical Evidence-Based Strategies

Improving the performance of this benchmark can be accomplished through various ways to decrease preventable falls. Strategic planning will provide a direction in making tough decisions for Medical Mercy Center to deliver superior service to their patients and prevent falls, reducing readmission rates. This policy proposal will support MMC’s leadership to acknowledge a weakness within the organization and implement ways to improve those areas of underperformance.

A lack of communication between staff has caused the fall rates to increase in the center. The “SBAR” concept (situation, background, assessment and, recommendations) is a great tool for maintaining effective communication. Communicating with the staff by using the “SBAR” concept will significantly reduce the chances of miscommunication from the staff and decrease any preventable falls from happening again.

Each time a nurse assesses a patient, using the SBAR concept will support them in identifying the patient’s situation, background, and application recommendations. This will be a great resource in which nurses can then contribute to an enhanced assessment and recommendations on what the patient will need for future treatment. (Lee., Dong,  Lim, Poh., & Lim, 2016).

Strategies should be established for patients who are at risk for falls, which are known to cause injuries to patients. There also should be ways to alert employees if patients are falling more often or patients that could potentially be at risk of falling. Implementing a color-coded system identifying a patient as a fall risk will support decreasing falls and educating new staff about the program.

Proposed Policy

A policy is brought to the attention of the stakeholders and leaders of Mercy Medical due to the systematic failure of reoccurring falls. It is up to the leaders of this organization to bring about change to increase patient satisfaction and patient safety. It is vital to take in the necessary strategies to reduce falls from transpiring. These strategies can contribute to influencing high-quality patient care. (Rawlins, 2014)

Competent staff will support the decrease of stress brought on by an increased workload and the pressures of being short-staffed. Having a knowledgeable team would help when chaotic situations arise and patient care is jeopardized.

It would help relieve the pressures towards a single employee and help to keep each other accountable as a team and decrease unnecessary shortcuts made by an employee. Requiring reporting of fall incidents will help the organization find the areas of weaknesses within the staff and organization. Putting into practice inquiring about the employees’ needs will create a stress-free environment.

Alerts should be issued to patients who are at high risk for falls. Using a color-coded system identifying the fall risk will help employees lessen repeated falls. Educating patients and staff members about the fall prevention policy would be vital in applying safe practices. (Morse,2018)


Human errors are common, but they can be avoided by focusing on education and implementing safe practices. Mercy Medical does not have to be a part of patient fall statistics. Implementing these policies within the organization will provide exemplary safe practices to serve as a role model for organizations and those within the organization.

It’s up to the leaders at Mercy Medical to set the right policies and make impacting changes that would enhance the quality of patient care. We may never be able to prevent patient falls completely, but with strategic efforts and skilled decision-making, we will provide our staff with the best opportunities to minimize falls and maximize patient care.

MMC Fall Prevention Policy

Effective date: October 14, 2019


To reduce and avoid falls by medication, ensuring proper nurse assessments and reducing risks to provide excellent quality care and correct usage of preventive and protective measures


  1. All patients should be adequately assessed and classified as to what type of fall risk they are identified when being admitted according to the policy and procedures of Mercy Medical. If any patients are considered high fall risk, all alerts, preventative, and protective measures are considered and must be put in place to ensure proper
  2. If a patient has a fall, the fall must be reported and documented in the system and a written report.
  3. All staff and leadership must be notified of an unlikely event and must be handled appropriately with the necessary actions for the patient to be taken care
  4. The patient must be adequately informed and given instructions and a detailed summary of the

III. Procedure:

  1. If an unlikely event occurs, the fall must be reported to the manager and director.
  2. An incident report must be filled out on the detailed location, type of fall and description of the
  3. A thorough patient follow-up must ensue and all safety precautions should be taken into effect.
  4. A follow-up meeting should be held with the manager and all leadership, including staff, to ensure the incident does not occur


Butcher, L. (2017, June 1). The No-Fall Zone. Retrieved from https://www.hhnmag.com/articles/6404-Hospitals-work-to-prevent-patient-falls.

Lee, S. Y., Dong, L., Lim, Y. H., Poh, C. L., & Lim, W. S. (2016). SBAR: towards a common interprofessional team-based communication tool. Medical Education, 50(11), 1167– 1168. https://doi-org.library.capella.edu/10.1111/medu.13171

Morse, J. M. (2008). Preventing patient falls: Second edition. Retrieved from https://ebookcentral-proquest-com.library.capella.edu

Rawlins, M. D. (2014). Engaging with health-care policy. The Lancet, 383, S7-8. doi:http://dx.doi.org.library.capella.edu/10.1016/S0140-6736(14)60048-9

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