Policy Proposal

An organizational benchmark is required for monitoring quality improvement, and underperformance can impair the provision of quality care and the organization’s operations, making it critical to implement policies and practice guidelines to enhance performance in these areas. This proposal aims to ensure the provision of excellent treatment that satisfies the requirements specified by local, state, or federal health care regulations, as well as to enhance the organization’s performance in the designated benchmark areas, including HbA1c tests and diabetic foot exams. A proposal to analyze the possible effects of environmental elements and propose ethical, evidence-based practice guidelines to enhance targeted benchmark performance is required to modify policies to improve care.

The Need for Creating a Policy and Practice

To ensure that patients receive excellent treatment and that the organization functions effectively, it is critical to develop policy and practice guidelines to overcome a deficiency in reaching a benchmark metric set by local, state, and federal healthcare policies and regulations. The present organizational standard and the numerical score for underperformance must be thoroughly analyzed to determine the areas that require improvement. The falling Hgba1c test and poor foot examination rate to avoid diabetic problems are the benchmark underperformance indicators for this organization. The underperformance of the benchmark has the potential to impact the organization’s operations and the provision of excellent care in a variety of ways. A decrease in Hgba1c examinations could result in individuals not obtaining proper diabetic therapy, resulting in health complications. The low incidence of foot examination may result in missed possibilities to prevent and manage foot problems, which are frequent among diabetics.

Increased healthcare expenses, poor patient satisfaction, and decreased patient outcomes are all potential consequences of not making any adjustments. The drop in Hgba1c examinations and low foot examination rate underscores the need for policy and practice guidance to address this benchmark underperformance. The drop in Hgba1c checks means that patients are not receiving the necessary level of care and the low incidence of foot examinations shows that opportunities to prevent and control diabetic problems are being lost (Attal et al., 2019). The organization can guarantee that patients receive the right level of care and that chances to prevent and treat diabetes complications are not missed by establishing policy and practice standards.

Current Benchmark For The Organization And The Numeric Score For The Underperformance

According to the performance dashboard indicators in Assessment 1, the current benchmark for the organization is falling short in two areas: Hgba1c exam and the foot examination rate. The numerical score for the Hgba1c exam underperformance entails a sharp rise from the second quarter of 2020, 58% to 78% in the 3rd quarter, and a further steep decline of 8% to end the year at 64%. The low foot examination rate has been steadily declining from the first quarter of 2020 to 48 % by the end of the third quarter to a slight increase of 14% to end the year at 62%.

How the Benchmark Underperformance Potentially Affecting The Provision Of Quality Care Or The Operations Of The Organization

Underperformance in the Hgba1c exam and foot examination rate could have a substantial influence on the organization’s quality of care. The Hgba1c test is vital for diabetes treatment since it assesses a patient’s average blood sugar level over the previous two to three months. A decrease in Hgba1c exam rates can signify that diabetic patients are not receiving proper treatment and may be at risk for diabetes-related problems, including neuropathy, retinopathy, and nephropathy (Attal et al., 2019). This can result in higher healthcare expenses, more hospitalizations, and lower patient satisfaction. Similarly, a low incidence of foot examination might have harmful repercussions for diabetic patients. Foot exams are critical in preventing and treating foot issues, which are frequent among diabetics. A low incidence of foot examination might suggest that patients are not receiving proper foot care and are at risk of foot ulcers and amputations. This can result in higher healthcare expenses, less mobility and independence, and lower patient satisfaction.

Potential Repercussions of not Making any Changes

If the organization does not take action to address the benchmark underperformance, the quality of care delivered to patients may continue to decline, resulting in adverse patient outcomes and a drop in patient satisfaction. This, in turn, can lead to lower income and diminished community confidence in the organization (Shamim et al., 2021). Noncompliance with benchmark requirements established by local, state, or federal healthcare policies or legislation may also result in sanctions and reduced funding possibilities for the organization.

Proof that Backs Up My Claims

The data on the performance dashboard clearly shows a drop in the Hgba1c exam and foot examination rate, which supports the conclusions. This decrease is also supported by relevant literature and research demonstrating the usefulness of frequent Hgba1c and foot examinations in the prevention and management of diabetes-related problems. Relevant studies and industry data also indicate the potential implications of not making any adjustments, such as decreasing patient satisfaction, lost revenue, and penalties for noncompliance.

Summary of the Proposed Organizational Policy and Practice Guidelines

The recommended organizational policy and practice guidelines aim to solve the performance dashboard indicators’ observed benchmark underperformance in the Hgba1c exam and foot examination rate (Herman et al., 2023). The relevant performance criteria addressed by the policy proposal are mandated by local, state, or federal healthcare policies or laws and include

  1. Ensuring staff members get regular education and training to ensure they understand the relevance of Hgba1c tests and foot assessments in preventing diabetic complications.
  2. Implementation of a solid system for tracking and monitoring Hgba1c and foot examination performance.
  3. Allocation of sufficient resources, including personnel and equipment, to enable the delivery of Hgba1c and foot exams.
  4. Policy and practice recommendations should be reviewed and evaluated regularly to verify their usefulness in enhancing benchmark performance.

The proposed policy is intended to guarantee that the organization complies with appropriate local, state, or federal healthcare rules or legislation while simultaneously providing patients with high-quality treatment (Herman et al., 2023). The organization must improve its benchmark performance, improve patient outcomes, and retain its commitment to providing quality healthcare services by applying these recommendations.

Effects of Environmental Factors on the Recommended Practice Guidelines

There are many important factors to bear in mind while considering the possible influence of environmental factors on proposed practice recommendations. First, regulatory factors must be considered. The suggested practice guidelines must follow all applicable local, state, and federal healthcare rules and legislation. This covers legislation governing patient privacy, data gathering, reporting, and patient care and treatment recommendations. Failure to comply with these standards may result in penalties, legal ramifications, and reputational damage to the organization. Aside from regulatory considerations, the availability of resources is also crucial. The suggested practice guidelines may require additional human resources, financial resources, and logistical concerns, such as physical space and support services (Herman et al., 2023). The company must ensure that it has the resources necessary to adopt and maintain the suggested guidelines. This entails hiring and training new employees, collecting appropriate money, and ensuring adequate physical space and support services are available.

Finally, the community’s cultural variety must be considered. The recommended practice standards must consider the patient population’s specific requirements and viewpoints, including variances in language, cultural norms, and beliefs (Herman et al., 2023). This necessitates cultural awareness and competency on the part of the organization’s employees, as well as a commitment to provide culturally appropriate treatment to all patients.

Ethical and Evidence-based Practice Guidelines

Several ways for improving performance for the specified benchmark are proposed in the (American Diabetes Association (2020) as evidence-based literature. For example, to enhance the Hgba1c exam, the proposed intervention is frequent monitoring of patients alongside education on the necessity of maintaining good blood sugar levels. This may be accomplished by setting up frequent visits with diabetes educators, sending out patient reminders, and offering patient-friendly instructional materials. To increase the incidence of foot examinations, American Diabetes Association (2020) proposes that diabetic patients have frequent foot exams and that patients be educated on the necessity of maintaining excellent foot health. This can be accomplished by including frequent foot exams in the patient’s treatment plan and teaching correct foot care procedures.

To ensure that these techniques are ethical and culturally inclusive in their implementation, they must take into account patients’ different cultural backgrounds and adjust training materials and interventions to their unique requirements (Chien et al., 2022). This entails working with neighborhood groups, employing cultural brokers, or giving instruction in many languages. The immediate impact of these changes on stakeholders’ work environments and job needs will almost certainly result in a greater burden for diabetes educators and healthcare professionals, as well as the need for extra resources such as staff and financing. On the other hand, the potential advantages of improved health outcomes and higher patient satisfaction should be factored into the decision-making process.

Stakeholders’ Involvement in Further Development and Implementation Proposed Policy and Practice Guidelines

It is critical to involve stakeholders and groups in the ongoing development and execution of the proposed policy and practice guidelines since they are critical to the policy’s success. The participation of various stakeholders and groups can result in a more complete and successful policy that benefits everyone in the company and community. Patients are the first stakeholders who must be included. They are the recipients of healthcare services, and their experiences and input are critical in assessing the policy’s efficacy (Rodrigues et al., 2020). Patients’ participation may assist in ensuring that the proposed policy meets their needs and expectations and provide useful input into how the policy might be improved.

Healthcare professionals and personnel are another set of stakeholders that must be included since any policy changes will directly touch them. Additionally, their involvement is critical in ensuring that the policy is realistic, practicable, and implementable. Involving healthcare professionals and workers may also ensure that the policy meets the issues and obstacles they experience daily, as well as creating buy-in and commitment to the policy. Healthcare organizations, government agencies, and other relevant entities must be included as the third set of stakeholders (Rodrigues et al., 2020). These groups have a substantial effect on the healthcare system and can assist in putting the strategy into action. Their participation may ensure that the policy is consistent with more profound healthcare policies and efforts, as well as help overcome any obstacles that may develop during implementation.

Strategies for Collaborating with the Stakeholder Group to Implement Proposed Policy and Practice Guidelines

The stakeholder group is critical to the successful implementation of the suggested policy and practice standards. Their cooperation is crucial for effective implementation because it guarantees that everyone is on the same page and working toward the same objective. Stakeholders can contribute useful input and recommendations to enhance policy and practice standards (Muchiri et al., 2018). They may also assist in identifying any issues or hurdles that may occur during implementation and working together to find solutions to these challenges. Several ways for collaborating with the stakeholder group during the implementation phase exist.

Foremost, regular communication is essential. It is critical to keep stakeholders informed and up to date on the implementation process’s progress (Muchiri et al., 2018). This can be accomplished via frequent meetings, email updates, or a dedicated website or portal. Second, including stakeholders in the planning and decision-making process is critical. Focus groups, questionnaires, and one-on-one sessions can all be used to accomplish this. Stakeholders can contribute useful insights and views that can aid in the refinement of policy and practice standards. Finally, it is critical to equip the stakeholder group with the appropriate resources and assistance to enable effective implementation. This might include chances for training and professional development, access to appropriate information and resources, and assistance from relevant departments and teams inside the business.


Addressing the benchmark underperformance in the Hgba1c exam and foot examination rate is critical for maintaining excellent treatment and seamless organization operations. The recommended policy and practice guidelines are supported by evidence-based research and are in accordance with local, state, and federal healthcare policies and legislation. The involvement of important stakeholders and groups is critical to the success of the proposed changes, and their engagement with the organization is critical to the policy’s successful implementation. The suggested adjustments are intended to have a favorable influence on the stakeholders’ work environment and job requirements by adopting ethical and culturally inclusive practices.


American Diabetes Association. (2020). Improving care and promoting health in populations: Standards of Medical Care in diabetes-2020. Diabetes Care43(Suppl 1), S7–S13. https://doi.org/10.2337/dc20-S001

Attal, S., Mahmoud, M. H., Aseel, M. T., Candra, A., Amuna, P., Elnagmi, M., Abdallah, M., Ismail, N., Abdelrazek, A., Albaw, D., Albashir, A., & Elmahdi, H. (2019). Indicators of quality of clinical care for type 2 diabetes patients in primary health care centers in Qatar: A retrospective analysis. International Journal of Endocrinology2019, 3519093. https://doi.org/10.1155/2019/3519093

Chien, L. J., Slade, D., Dahm, M. R., Brady, B., Roberts, E., Goncharov, L., Taylor, J., Eggins, S., & Thornton, A. (2022). Improving patient-centered care through a tailored intervention addressing nursing clinical handover communication in its organizational and cultural context. Journal of Advanced Nursing78(5), 1413–1430. https://doi.org/10.1111/jan.15110

Herman, W. H., Bullock, A., Boltri, J. M., Conlin, P. R., Greenlee, M. C., Lopata, A. M., Powell, C., Tracer, H., & Schillinger, D. (2023). The National Clinical Care Commission report to Congress: Background, methods, and foundational recommendations. Diabetes Care46(2), e14–e23. https://doi.org/10.2337/dc22-0611

Muchiri, J. W., Gericke, G. J., & Rheeder, P. (2018). Stakeholders’ perceptions of dietary and related self-management challenges and education program preferences for type 2 diabetes adults. Journal of Endocrinology Metabolism and Diabetes of South Africa24(1), 1–9. https://doi.org/10.1080/16089677.2018.1541211

Rodrigues, A. M., Haste, A., Penn, L., Bell, R., Summerbell, C., White, M., Adamson, A. J., & Sniehotta, F. F. (2020). Stakeholders’ perceptions and experiences of the National Health Service diabetes prevention program in England: a qualitative study with service users, intervention providers and deliverers, commissioners, and referrers. BMC Health Services Research20(1), 307. https://doi.org/10.1186/s12913-020-05160-2

Shamim, M., Alhakbani, M. S. A., Alqahtani, M. S. B., Alharthi, O. S. O., & Alhaqbani, Y. J. N. (2021). Knowledge, attitude, and practice regarding diabetic foot care among Saudi and non-Saudi diabetic patients in Alkharj. Journal of Family Medicine and Primary Care10(2), 859–864. https://doi.org/10.4103/jfmpc.jfmpc_1681_20

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