NHS FPX 6004 Assessment 2 Policy Proposal

NHS FPX 6004 Assessment 2 Policy Proposal

Student name

Capella University

NHS-FPX6004 Healthcare Law and Policy

Professor name

Submission Date

Policy Proposal

The use of health policy proposals is aimed at resolving problems within the healthcare sector and improving, in general, within certain spheres. The policy proposal evaluates the necessity of the policy changes to improve medication practices in Shannon Medical Center (SMC) (Shannon Medical Center, n.d.). The evaluation examines the existing issues of medication errors, besides outlining the role of policy changes. Within the evaluation, a series of recommendations to enhance the SMC medication administration practice will be proposed, taking into consideration the environmental factors, which include the level of staffing and regulatory mandates. It also entails ethical guidelines for the proposed recommendations and existing approaches to consult stakeholders during the introduction of proposed policy changes.

Need for the Development of Policies and Guidelines

The fundamental standards in SMC, which they have maintained, are accuracy in medication administration, patient identification, and national safety compliance. The fundamental guideline of medication administration is that the number of errors is less than 5 per 10,000 medication administrations, which is revealed in the Centers for Medicare & Medicaid Services (CMS) and Institute for Safe Medication Practices (ISMP) guidelines (Mutair et al., 2021). The medication error rate at the SMC is 8 errors per 10,000 medication aids, therefore, exceeding the national standard and an obvious indication of poor performance (Shannon Medical Center, 2024).

• Impact of Benchmark Underperformance on Quality Care

Poor medication safety benchmark can affect the operation of hospitals alongside the quality care experience. Patient safety is severely endangered due to the occurrence of medication errors, increasing the number of adverse drug events (ADEs) that cause longer hospitalization and other interventions and even death (Mousa et al., 2024). The satisfaction of the patients deteriorates as patients lose trust in the hospital due to the adverse effects of the medications. Nevertheless, this reduces the scores on hospital consumer assessment of healthcare providers and systems (HCAHPS), which also impacts the reputation and the retention of patients (Liu et al., 2020).

There is inflation in operational expenditures when patients develop ADE-related complications since the hospitals have to compensate them with their extended hospitalizations and the additional assistance the staff members have to provide them (Mousa et al., 2024). Without medication safety benchmarks, the hospital will be on the brink of regulatory compliance failure since losing accreditation of the Joint Commission and punishment on reimbursements by the Centers for Medicare & Medicaid Services (CMS) can be triggered (Kfuri et al., 2020). Recurring medication errors are complex and have adverse effects on the morale of the personnel and result in stress and legal issues. These medication safety concerns are resolved by the need to improve protocols that will assist in quality care delivery as well as operational efficiency.

• Repercussions of Inaction

Low standards of performance begin to have a drastic impact on the healthcare organizations as they influence their accreditation, financial, and legal positions. The financial viability of the hospital is under threat as the CMS will penalize and withhold the status of the Joint Commission and decrease Medicare/Medicaid funding in case of recurrent failures to meet safety standards (Kfuri et al., 2020). These are direct implications of non-compliance in the form of higher malpractice insurance premiums and costly legal verdicts, and loss of federal allocation that influences the availability of resources (Hicks and Stavropoulou, 2020).

This leads to negative effects like a lower reputation of the hospital or even less patient confidence due to continued medication errors and nonadherence (Hicks and Stavropoulou, 2020). The existence of national patient safety standards violations not corrected will attract regulatory attention that would lead to both state and federal investigations and financial fines, and prosecution against harmed patients. The hospital should proactively improve quality and safety measures since such proactive efforts will assist in safeguarding the integrity of operations and gain the trust of patients.

Proposed Organizational Policy and Guidelines

Potential Effects of Environmental Factors

Environmental factors such as the number of staff, the hospital infrastructure, and technology available will influence the implementation of the recommended practice guidelines at SMC. Lack of adequate staff necessitates performing medication safety protocols, as well as the malfunction of barcode medication administration (BCMA) systems (Mulac, 2021).

The SMC must also ensure a physical environment that is safe to patients and has well-maintained medication storage facilities, as well as easy-to-read patient identification signs (Shannon Medical Center, n.d.). There are challenges in implementing safety measures since the different departments do not always communicate with each other.

The guidelines suggested must take into account the regulations that are applicable in this field. The hospital should comply with all the laws of the federal and state bodies of CMS and The Joint Commission to maintain the eligibility of its reimbursement and avoid fines (Kfuri et al., 2020). The regulations that are in place need the hospitals to adhere to the medication safety standards strictly, and consequently impact the scope of the guidelines as well as their implementation.

Sufficient funding is a key element since it allows acquiring staff training, technology upgrades, and audit systems (Stek & Schiele, 2021). When the financial constraint sets in, the hospital will be forced to choose the areas of essential improvement that should be prioritized and put to rest initially on the concerted effort of operational management and financial resource management to uphold safety standards.

Ethical and Practice Guidelines

The desired benchmark performance at SMC should be improved by ethical evidence-based practice guidelines that should concentrate on enhancing the accuracy of medication administration based on the use of BCMA and the electronic health records (EHR) system. There are several evidence-based solutions that can be used to improve performance by offering training of the BCMA technology staff, conducting frequent medication safety assessments, and improving the patient identification systems (Mulac, 2021).

Studies have shown that stable feedback systems among the staff members with regular competency exams, as well as the EHR system-generated real-time alerting functionalities, can be used to detect any medication discrepancies in delivery (Li et al., 2024). These measures have two-fold goals to reduce the medication mistakes and to facilitate the implementation of CMS and The Joint Commission National patient safety goals demand accurate identification of patients and safe medication practices.

The proposed changes will have direct positive impacts on the performance with the introduction of responsible and safety-oriented healthcare provider cultures. The strategies adopted will assist the healthcare facilities to ensure that they have stringent medication management systems that comply with the local, state, and federal healthcare policies, such as CMS CoP and The Joint Commission standards (Kfuri et al., 2020). BCMA implementation with EHR systems is compliant with the regulatory requirements to reduce medication errors that result in enhanced patient safety and hospital compliance (Mulac, 2021). The enhanced medication administration activities in hospitals reduce adverse drug events, and this reduces legal exposure and improves hospital image and accreditation status.

The education regarding these strategies should be provided in a comprehensive manner since it will guarantee ethical behavior and culturally competent care of patients and healthcare providers. The multiple language training programs and the culturally specific content can assist the hospital to become more inclusive by catering to the demographics of the patients (Cheraghi et al., 2023).

The beneficence, non-maleficence, and justice should be considered with appropriate attention to all patients irrespective of their cultural background to provide them with the best possible care (Cheraghi et al., 2023). The changes will have a direct impact on the working environments in terms of new workflow arrangements, increased technology application, and improved documentation practices (Cheraghi et al., 2023). The administrative operations will change towards data-driven procedures, and the members of staff will have to acquire new systems that require a planned change management, as it will help to see a successful transition.

Importance of Stakeholders

Effective execution of suggested policy and practice guidelines is achieved through ensuring the involvement of key stakeholders who are able to render changes effective, sustainable, and well accepted. Nurses, physicians, hospital administrators, and information technology (IT) staff need to actively participate during the policy implementation since they are the ones directly affected and have the knowledge to certify the practical implementation (Bhati et al., 2023).

It requires nurses and physicians to carry out the medication safety protocols, but the hospital administrators are in charge of the logistical issues, and IT staff are the ones who apply the technological tools such as BCMA and EHR systems (Bhati et al., 2023). Patient representatives and advocacy groups must be engaged in the ethical integrity of the policy to ensure that guidelines are based on patient-centered care principles.

The cooperation of these stakeholders ensures the provision of practice guidelines that provide wholesome solutions addressing the needs of healthcare professionals as well as patients. This policy is improved through the fact that the various perspectives that are gathered by the stakeholders are used to manage both clinical and operational, and technological needs (Bhati et al., 2023).

The input of stakeholders in the policy-making process allows organizations to find out the challenges that they will face in the future. The stakeholder engagement provides an organizational commitment to guidelines that will result in enhanced implementation success and longer-term compliance (Bhati et al., 2023). The combination of these stakeholders should aim at developing a single and effective method for benchmark improvement that does not compromise the organizational objectives and compliance with the regulations.

Strategies for Collaborating with Stakeholders

The stakeholder group will play a key role in the implementation of the proposed policy to ensure the policy remains effective and viable through their professional inputs of practice guidelines. The implementation of the medication safety protocols is conditional on the nurses and physicians who will incorporate barcode scanning and EHR systems to check patient information and monitor medication delivery (Mulac, 2021).

The hospital administrators will channel resources to the required staff members and training programs, and IT personnel will take care of the technological systems needed to implement the guidelines (Bhati et al., 2023). The alignment of the stakeholders and their continuous enhancement can be accomplished by regular training programs and interactive workshops, along with the feedback mechanisms that are performed regularly.

The involvement of employees in patient care makes them crucial partners, as they know what the challenges and benefits are to maximize the workflow. The involvement of stakeholders in policy formulation and execution will enable the organization to identify issues beforehand and simplify the guidelines to use in the everyday routine (Bhati et al., 2023). This group is critical in terms of helping overcome the organizational resistance to change and ensuring constant compliance with the new standards (Bhati et al., 2023). The contributions and commitment of the stakeholder group result in a strong team that focuses on meeting policy objectives, and patient safety is improved.

Conclusion

A full medication administration policy in SMC is crucial to the successful improvement of patient safety outcomes, regulatory adherence, and the effectiveness of operations. The attendance of healthcare providers and administrators, with the help of IT professionals, allows SMC to resolve medication administration mistakes and meet the set standards. The evidence-based and ongoing partnership-supported proposed policy will develop a safety culture and improve patient outcomes at Shannon Medical Center.

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