Category: Nursing

Write a 46 page policy proposal and practice guidelines for improving quality and performance associated with the benchmark metric underperformance you advocated for improving in Assessment 1.

Collapse AllIntroduction

In advocating for institutional policy changes related to local, state, or federal healthcare 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 healthcare. This assessment offers you an opportunity to take the lead in proposing such changes.

As a master’s-level healthcare 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 and ensuring compliance with various healthcare regulatory pressures. This assessment offers you an opportunity to take the lead in proposing such changes as well.

Instructions

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.

Requirements

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 healthcare policies or laws. Use your topic from Assessment 1 to complete this.
• What is the current benchmark for the organization and the numeric score for underperformance?
• How is the benchmark underperformance affecting the provision of quality care or the organization’s operations?
• 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 healthcare policy or law that prescribes relevant performance benchmarks that your policy proposal addresses (using your Advocacy Issues topic from the AHA).
• Keep your audience in mind when creating this summary statement.
• 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 healthcare 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/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 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 summary statement should be succinct (about one paragraph). Overall, your proposal should be 46 pages in length.

Supporting Evidence

Cite 35 references to current and scholarly research, case studies, or best practice guidelines to support your analysis and recommendations.

Competencies Measured

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

• Competency 1: Analyze relevant healthcare laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
• Explain and interpret for stakeholders the need for 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.
• Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
• Summarize a proposed organizational policy or practice change guideline and analyze the potential effects of environmental factors on recommended practice guidelines.
• Competency 3: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, to inform healthcare laws and policies for patients, organizations, and populations.
• Explain how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change.
• 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 or practice change to improve quality and outcomes.
• Present strategies for collaborating with a stakeholder group to implement 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.
• Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

Collapse AllCriterion 1

Explain and interpret for stakeholders the need for 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.

Distinguished

Explains to stakeholders the need for 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. Clearly articulates the effects of benchmark underperformance and draws sound conclusions about the potential repercussions of inaction, based on credible evidence and relates information to stakeholder group.

Proficient

Explains to stakeholders the need for 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.

Basic

Identifies to stakeholders the need for 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. irrespective of a particular need.

Non Performance

Does not explain to stakeholders the need for 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.

Criterion 2

Summarize a proposed organizational policy or practice change guideline and analyze the potential effects of environmental factors on recommended practice guidelines.

Distinguished

Succinctly summarizes a proposed organizational policy and practice guidelines; analyzes the potential effects of environmental factors on recommended practice guidelines. Identifies clear cause-and-effect relationships and the influence of those factors on specific recommendations.

Proficient

Summarizes a proposed organizational policy and practice change guidelines and the potential effects of environmental factors on recommended practice guidelines.

Basic

Provides a summary that paints an unclear picture of a proposed organizational policy and practice guidelines and/or does not expand on environmental factors that can affect recommended practice guidelines.

Non Performance

Does not summarize a proposed organizational policy and practice guidelines or identify environmental factors that can affect recommended practice guidelines.

Criterion 3

Explain how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change.

Distinguished

Explains how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change. Provides clear and compelling justification, substantiated by credible evidence.

Proficient

Explains how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change.

Basic

Identifies how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change but does not provide context or rationale to support the content.

Non Performance

Does not explain how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change.

Criterion 4

Explain why particular stakeholders and groups must be involved in further development and implementation of a proposed policy or practice change to improve quality and outcomes.

Distinguished

Provides a perceptive and succinct explanation of why particular stakeholders and groups must be involved in further development and implementation of a proposed policy and practice guidelines. Offers clear and convincing rationale for stakeholder and group engagement and how it strengthens policy and facilitates changes in practice to improve quality outcomes.

Proficient

Explains why particular stakeholders and groups must be involved in further development and implementation of a proposed policy and practice guidelines change to improve quality and outcomes.

Basic

Identifies stakeholders and groups who are not the most logical choices to be involved in further development and implementation of a proposed policy and practice guidelines and implementation of a proposed policy or practice change to improve quality and outcomes.

Non Performance

Does not explain why particular stakeholders and groups must be involved in further development and implementation of a proposed policy or practice change to improve quality and outcomes.

Criterion 5

Present strategies for collaborating with a stakeholder group to implement a proposed policy and practice guidelines.

Distinguished

Presents strategies for collaborating with a stakeholder group to implement a proposed policy and practice guidelines. Makes a compelling case for the importance of stakeholder collaboration and considers stakeholder perspectives by addressing possible objections.

Proficient

Presents strategies for collaborating with a stakeholder group to implement a proposed policy and practice guidelines.

Basic

Presents stakeholder collaboration strategies for implementing a proposed policy and practice guidelines that lack clear relevance or insight into the positions and perspectives of the stakeholder group.

Non Performance

Does not present strategies for collaborating with a stakeholder group to implement a proposed policy and practice guidelines.

Criterion 6

Organize content so ideas flow logically with smooth transitions.

Distinguished

Organizes content so clarity is enhanced and all ideas flow logically with smooth transitions.

Proficient

Organizes content so ideas flow logically with smooth transitions.

Basic

Organizes content with some logical flow and smooth transitions.

Non Performance

Does not organize content for ideas to flow logically with smooth transitions.

Criterion 7

Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.

Distinguished

Supports main points, assertions, arguments, conclusions, or recommendations with relevant, credible, and convincing evidence. Skillfully combines virtually error-free source citations with a perceptive and coherent synthesis of the evidence.

Proficient

Supports main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.

Basic

Sources lack relevance or credibility, or the evidence is not persuasive or explicitly supportive of main points, assertions, arguments, conclusions, or recommendations.

Non Performance

Does not support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.

Write a 35 page report for a senior leader that communicates your evaluation of current organizational or interprofessional team performance, with respect to prescribed benchmarks set forth by government laws and policies at the local, state, and federal levels.

Collapse AllIntroduction

In this assessment, you will delve into the world of healthcare laws, guidelines, policies, and benchmarks. As a healthcare professional and leader, it is essential to understand the policies governing your organization and how they align with broader healthcare laws and industry benchmarks. Each member of the healthcare team needs to understand what is needed to provide efficient, effective, and evidence-based care. Through this assessment, you will develop critical analysis skills that will enhance your understanding of healthcare governance and quality improvement efforts.

The purpose of this assessment is to analyze a policy related to your professional practice, organization, or community and compare it to relevant healthcare laws, guidelines, and policies. Then, you will examine how policy, guidelines, and laws align with measurable healthcare benchmarks and implications for quality improvement.

Instructions

Use the to complete this assessment.

1. Topic Selection: Choose a topic of interest that you would like to work in your organization or one where you have worked before or are interested in working.

• Look at the American Hospital Association, Center for Medicare & Medicaid, the Institute of Health Care Improvement, or the Joint Commission Patient Safety Goals.
• If you cannot locate one, look at local, state, or federal issues.

1. Policy Application: Find a policy, set of guidelines, or government regulations and apply it to the organizations work on the chosen topic. You may choose a policy you have access to from your organization. Other sources of policies include those published online from a different healthcare organization.

• Describe clearly how the selected policy complies with or diverges from the requirements outlined in a related healthcare law, providing evidence to support your position.
• Discuss the potential legal, ethical, or financial implications of non-compliance with the policy and its alignment with healthcare law or professional guidelines.
• Consider the consequences for individual practitioners, stakeholders, and the healthcare organization.
• Examples of Laws, Regulations, and Standards:
• Centers for Medicare & Medicaid Services (CMS) Federal regulations and guidance.
• CMS Hospital Readmissions Reduction Program (HRRP).
• CMS Inpatient Quality Reporting Program (IQR).
• CMS Improving Medicare Post-Acute Transformation Act of 2014 (IMPACT Act) is a federal law that standardizes patient assessment data in post-acute care settings.
• CMS Social Determinants of Health (SDOH) requirements.
• The Joint Commission Standards and Measures.
• Commission on Accreditation of Rehabilitation Facilities (CARF).
• Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network.
• National Database of Nursing Quality Indicators (NDNQI).
• Agency for Healthcare Research and Quality (AHRQ).
• National Committee for Quality Assurance (NCQA) – Healthcare Effectiveness Data and Information Set (HEDIS) measures.
• The Patient Safety and Quality Improvement Act of 2005 (PSQIA) protects healthcare workers who report unsafe conditions at their practices. The law encourages individuals to report medical errors while maintaining patient confidentiality.

1. Benchmark Comparison: Identify a benchmark or strategic goal and compare it to the policy, guideline, or regulation and goal that is not at the desired goal or range.

• A benchmark in healthcare is a standard or point of reference used to measure and compare the performance of healthcare organizations, departments, or individual clinicians.
• Benchmarks are used to identify areas for improvement and set goals for quality improvement.
• These benchmarks could include national quality indicators, best practices recommended by professional organizations, or performance metrics set by regulatory agencies.
• If you do not have access to your organization’s benchmarks, one of the resources on the reading list can be utilized to access benchmarks.
• Describe the benchmarks associated with the healthcare law, policy, or guideline, and clearly articulate the connections between benchmarks and policy. There may be more than one benchmark for a topic, but only one is needed.
• The comparison should include the benchmarks numerical value.
• example: This information is an example of available data that could be used to build a case for what needs improvement based on underperformance and help justify the consequences of not meeting the standards set for the CMS Core Measures. Some hospitals share lots of detail, while others provide limited information.

1. Metric Analysis: Look at the metric or measure that is not being met or in compliance with the policy, guideline, or regulation and analyze what needs to be added, removed, or developed to ensure the benchmark is met.

• Consider how an Interprofessional Education (IPE) team can develop a Quality Improvement (QI) plan to improve these outcomes.
• Analyze the consequences of not meeting prescribed benchmarks and the impact this has on healthcare organizations or teams.
• The reading list is a good place to find this type of information.
• Be sure to clearly identify implications and acknowledge assumptions underlying your analysis.

1. Sustainability and Ethics: Describe what is needed to ensure that the project plan will be sustainable, efficient, effective, and evidence-based.

• Consider how adherence to benchmarks can drive positive outcomes in patient care, safety, and overall organizational performance.
• Explain how you can ensure the solution is ethical and protects vulnerable and diverse patient populations.
• Advocate for ethical and sustainable actions directed toward an appropriate group of stakeholders, arguing effectively for recommended actions with a clear and perceptive explanation of the ethical principles and sustainability goals to guide such actions.

Note: Ensure your data are Health Insurance Portability and Accountability Act (HIPAA) compliant. Do not use any easily identifiable organization or patient information.

Report Requirements

The report 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.

• Describe how the selected policy complies with or diverges from the requirements outlined in the healthcare law.
• Identify benchmarks associated with a healthcare law, policy, or guideline.
• For additional information on benchmarks, you may go to the AHRQ website and explore their Data Tools. Use the for step-by-step instructions.
• Evaluate dashboard metrics associated with benchmarks set forth by local, state, or federal healthcare laws or policies.
• Identify a benchmark underperformance.
• Analyze the consequences of not meeting prescribed benchmarks and the impact this has on healthcare organizations or teams.
• Discuss the potential legal, ethical, or financial implications of non-compliance with the policy and its alignment with healthcare law or professional guidelines.
• Consider the consequences for individual practitioners, stakeholders, and the healthcare organization.
• Advocate for ethical and sustainable actions, directed toward an appropriate group of stakeholders, needed to address a benchmark underperformance.
• Organize content so ideas flow logically with smooth transitions.
• Proofread your report, 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 evaluation and analysis.
• Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.
• Be sure to apply correct APA formatting to source citations and references.

Report Format and Length

Format your report using current APA style.

• Use the to help you in writing and formatting your report. Be sure to:
• Remember to utilize the authoring organization as the group author if specific authors are not noted.
• If there is no date (n.d.), provide the date retrieved and from.
• Include more information than the URL.
• Include a title and reference page. Do not use an abstract.
• Your report should be 35 pages in length, not including the title page and references page.

Supporting Evidence

Cite 46 credible, current, and scholarly references. Include the policy, law, or guidelines.

Competencies Measured

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

• Competency 1: Analyze relevant healthcare laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
• Describe how a selected policy complies with or diverges from the requirements outlined in a related healthcare law.
• Analyze the consequences of not meeting prescribed benchmarks and the impact this has on healthcare organizations or teams.
• Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
• Advocate for ethical and sustainable actions, directed toward an appropriate group of stakeholders, needed to address a benchmark underperformance.
• Competency 3: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, to inform healthcare laws and policies for patients, organizations, and populations.
• Identify benchmarks associated with a healthcare law, policy, or guideline.
• Evaluate a benchmark underperformance in a healthcare organization or interprofessional team that has the potential for greatly improving overall quality or performance.
• Competency 5: Produce clear, coherent, and professional written work, in accordance with Capella’s writing standards.
• Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Complete the Capstone Project Template Draft Use this template to complete the assignment BSN355 Capstone Project Proposal Template . What is the project question? In other words what are you ultimately trying to figure out? What is the title of your project? Who will benefit from your project? Where are the people located that will benefit from your project? How long will your project take from beginning to end? Budget requirements of your project (How much money will it take to implement your project?) Why did you decide to do this project? What do you hope to achieve by doing this project? What do you need to do to help you complete this project? Will your project have long term effect? If so. What are they? If none. Why not? Will the project be sustainable? If so. How will you sustain the project? How will your project be evaluated? Are there any risks associated with the project? Is there anything that may prevent your project form succeeding? If so, what? This draft copy may be changed throughout the semester as you develop your project proposal. Draft copy will be submitted by Sunday 11:59 week 4 Final copy will be submitted in week 13. Make sure you keep a copy of your assignments and discussion questions from this course, they will be used in the BSN 435, Scholarship and Evidence-Based Practice in Nursing and BSN 485 Capstone Leadership.

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Robert Carter posted Jan 25, 2026 2:23 PM

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I work at a long-term drug and alcohol rehabilitation facility. We assess overall pain using a 0-10 Numerical Rating Scale (NRS). We adopted this subjective scale to measure a patients pain experience. This pain scale rating tool is proven to be the best method for our facility.

Nursing will document our patients pain scores at set intervals when they present nursing with pain and vitals and pre- and post-pain intervention. Patients rate their pain on a scale of 0-10 with zero being no pain and ten being the worst pain. In our Electronic Medical Record (EMR) we have dictated pain scores that set off flows based on the scores being above or below a certain number.

I like how the NRS is fast and easy to document, especially how hectic healthcare can be. This also allows you to chart a number and graph it over time to see if interventions are helping. With that being said, there are many limitations to this scale. Patients who are oriented to the pain scale tend to only give three scores: 0,5, or ten. Some cultures are also more expressive with pain than others, which can lead to biased scores (Ball et al., 2022). This tool only addresses pain intensity and does not allow you to get further explanation about pain quality, location, or if it affects daily functions. Also, everyone has a different perception of what a number characterizes; what is a seven to one patient may be a four to another.

To overcome these limitations, we ask all our patients the same questions about their pain when we do their admission assessment, so they understand how to use the scale. We also teach them that we will be asking follow-up questions to better understand their pain. Another thing we do is follow up with the patients by asking them, How is this pain affecting your ability to move, perform activities of daily living, or get sleep. Patient comprehension will be improved by verbal-visual support for the numerical scale expressions and scales utilized (Yeilyurt et al., 2021).

I do like using the NRS as it is a quick way to assess a patient’s pain. But when using this scale, I like to follow up with questions to better understand their pain. In the future, I think there should be more emphasis on pain scales that address pain intensity and functional loss.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2022). Seidel’s guide to physical examination an interprofessional approach (10th ed.). Elsevier.

Yeilyurt, M., Necmettin, & Faydal, S. (2021). Evaluation of patients using numeric pain-rating sc ales.

Please complete 2 of these. One topic being use of LEAF wireless motion sensor and pressure mats to help with pressure ulcers. I am currently on a med Serg Cardiac Stepdown unit.

Reflect on the past 7 weeks and share your insights on the practice-ready skills that you have developed thus far. Address each of the following prompts with your reflective post: How have the skills you developed in creating the planning phase project documents helped to prepare you for practice in informatics? How did these skills help you to meet each of the course outcomes? Be sure to cite examples as they relate to practice readiness and course outcome attainment, not merely a listing of assignments. CO: 1 Synthesize knowledge, apply person-centered principles and concepts from nursing-informatics and project management to develop project plans and teams. (PO 1) CO: 2 Demonstrate effective leadership skills and advanced roles that promote successful planning, management and evaluation of projects and teams. (POs 3, 5) CO: 3 Incorporate the standards of practice for nursing informatics that exemplify professional values and scholarship to support professional growth, leadership skills and advance personal development. (POs 4, 5) CO: 4 Contribute to the body of nursing informatics knowledge through participation in and application of systematic utilization of evidence-based knowledge in creation of effective project plans and teams.

1. Physical Environment What are the boundaries of the community? What is the climate like? Describe air and water quality. Describe the type, condition, and overall appearance of housing and neighborhoods. Is specialized housing available for low-income, elderly, or disabled populations? How is waste collected and disposed of (including sewage, industrial waste, and toxic chemicals)? What environmental characteristics pose health risks or increase the potential for man-made or natural disasters? 2. Population What is the population size, and how stable has it been over time? Have there been any significant changes in population size or characteristics? What are the predominant racial/ethnic and religious groups? What is the age and gender distribution of the population? 3. Economics Who are the major employers in the community? What are the major occupations among individuals over 25 years of age? What is the median household income? What percentage of the population falls below the poverty level? this is located in Passaic, New Jersey

As you reflect on highly functional teams that you have been a part of or led, who was ultimately responsible for the work? Who was accountable for the work? Who were the stakeholders or subject matter experts? Who did the team need to keep informed as the work progressed? How will these role responsibilities be reflected in your project? Utilize the chart provided to identify the who-what-when-how for your project. Submit your chart and solicit feedback from your classmates. As you review your classmates’ charts, you may discover omissions from your own plan and can act upon those. FYI Project title: Reducing Lorazepam (Ativan) Administration Errors Using Targeted Clinical Decision Support in an Adult Mental-Health Units

Please see instruction attached and use the template below