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1 Running head: POLICY PROPOSAL Policy Proposal Marilyn Cao Capella University
2 POLICY PROPOSAL Abstract Dashboards provide important information on an organization’s performance regarding local, state, and federal laws and policies. Effective changes are based on this information for quality improvement. Mercy Medical Center found departments that are falling short of their benchmarks, such as heart failure rate of readmission, and a convincing proposal will get staff on board with the organization’s goals. The proposal details the need for policy changes, what the policy entails and its guidelines, potential challenges, and critical stakeholders.
3 POLICY PROPOSAL Need for Policy Changes This organizational policy proposal and its guidelines will support improvement in quality and performance of the benchmark metrics advocated for previously- heart failure rate of readmission. The local COPD readmission rate is 20.1 while the national readmission rate is 20.2. For pneumonia, local readmission rate is at 18.7 and national readmission rate is at 16.9. The local readmission rate for heart failure is 26.4, but the national readmission rate is lower at 22 (VilaHealth, n.d.). There is potential for improvement to close the largest gap on the 4.4 deficit. Benchmark underperformance affect the quality of care being provided and the operations of the organization. Preventing avoidable readmissions will raise standards for our staff and improve patient outcome. The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals according to the quality of hospital care, so the organization will financially suffer with higher rates of readmission (Centers for Medicare & Medicaid Services, n.d.). Financial repercussions and decrease in patient volume are possible if policy changes are not made. Policy Description & Guidelines The purpose of this policy is to clarify guidelines to improve patient outcomes and ensure efficient organization operations. This policy has been established to ensure consistency in all documentation and procedures from staff at Mercy Medical Center to improve readmission rate of heart failure patients. The scope of this policy includes physicians, nurses, social workers, care coordinators, and pharmacists. Staff should expect a change in documentation systems and discharge planning processes at their respective departments. It is Mercy’s intention to streamline
4 POLICY PROPOSAL and decrease time spent on documentation to allow more patient time focused on education interventions. Enhancing discharge planning and documentation within the clinical staff will allow patients to customize their care to cater to their individual needs. Improving personalized care can prevent and reduce the readmission rate for patients. This policy calls for educational intervention for both the staff and patient. These implementations will decrease unnecessary

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