Capella University NHS FPX 6004 Policy Proposal Scoring Guide Worksheet

Write a 4-6-page policy proposal and practice guidelines for improving quality and performance associated with the benchmark metric underperformance you advocated for improving in Assessment.


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

Note: Remember that you can submit all, or a portion of, your draft policy proposal to Smarthinking for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.


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 health care policies or laws.
  • What is the current benchmark for the organization and the numeric score for the underperformance?
  • How is the benchmark underperformance potentially affecting the provision of quality care or the operations of the organization?
  • What are the potential repercussions of not making any changes?
  • What evidence supports your conclusions?
  • Recommend ethical, evidence-based practice guidelines to improve targeted benchmark performance prescribed by applicable local, state, or federal health care policy or law.
  • 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 health care policy or law?
  • How would you propose to apply these strategies in the context of Eagle Creek Hospital or your own practice setting?
  • How can you ensure these strategies are ethical and culturally inclusive in their application?
  • 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 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?
  • 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 summarizing to represent ideas from external sources.
  • Be sure to apply correct APA formatting to source citations and references.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:

Assessment 2 Example [PDF].

Policy Proposal Format And Length

It may be helpful to use a template or format for your proposal that is 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 should be succinct (about one paragraph). Overall, your proposal should be 4–6 pages in length.

Supporting Evidence

Cite 3–5 references to relevant research, case studies, or best practices to support your analysis and recommendations. Note: Faculty may use the Writing Feedback Tool when grading this assessment. The Writing Feedback Tool is designed to provide you with guidance and resources to develop your writing based on five core skills. You will find writing feedback in the Scoring Guide for the assessment, once your work has been evaluated. Portfolio Prompt: You may choose to save your policy proposal to your ePortfolio.

Competencies Measured

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

  • Competency 1: Analyze relevant health care laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
    • Analyze the potential effects of environmental factors on recommended practice guidelines.
  • Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
    • Recommend ethical, evidence-based practice guidelines to improve targeted benchmark performance prescribed by applicable local, state, or federal health care policies or laws.
  • Competency 3: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, to inform health care laws and policies for patients, organizations, and populations.
    • Explain the need for creating a policy to address a shortfall in meeting a benchmark metric prescribed by local, state, or federal health care policies or laws.
  • 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 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.
    • Use paraphrasing and summarizing to represent ideas from external sources.

Capella University NHS FPX 6004 Policy Proposal Scoring Guide Worksheet Example

Policy Proposal

Overall, between 2015 and 2016, Mercy Medical Center’s Specialty Operations and Maternity & Deliveries departments reduced the number of accidents. However, the orthopedic surgery and obesity programs departments of the hospital saw a considerable rise in the frequency of falls in 2016. Both the standards of the medical center and the well-being of the patients are gravely at risk from these accidents. This article shows why Mercy Medical Center needs to adjust its policies in order to achieve the suggested standards for reducing patient falls.

The proposed change is developing and implementing fall prevention programs throughout Mercy Medical Center to help alleviate fall rates for the orthopedic surgery and Obesity Divisions. This is because the health facility serves a lot of patients from Shakopee; hence reducing injury risks inside the orthopedic surgery and Obesity Divisions is vital. Also proposed is an increase in employee personnel to aid in lowering accident incidence and improving client results.

Need For Policy And Practice Guidelines

Mercy Medical Center needs to prioritize accidents or fall prevention in its Orthopedic Surgery and Obesity Departments. Miscommunication and understaffing are among the major factors contributing to frequent falls at the medical facility’s Orthopedics and Bariatric Services. Admittedly, preventing patient falls in healthcare facilities is a challenge shared by many health organizations across the country. 

The national average fall incidents in United States hospitals range between 3.3 to 11.5 falls per 1,000 patient days (Bouldin et al., 2013). Research has proven that the falls vary considerably by unit or department type, with high incidents recorded in hospitals working with the elderly, surgery, and physically disabled patients (Gygax, 2017). Mercy Medical Center is among the hospitals with high fall incident rates close to the national average, due to cultural differences and few staff members to attend to patients.

Patient falls in hospitals have a significant negative effect on the patient’s health, which derails their recovery process. The leading causes of high patient fall in hospitals include inadequate monitoring, miscommunication, non-compliance to fall safety protocols and practices, and understaffing (Sentinel Event, 2015).

According to Schwendimann, Bühler, and Milisen (2006), patient falls in medical centers often lead to negative outcomes, among them severe injuries, prolonged hospitalization, and legal responsibility to the hospital. Mercy Medical Center is vulnerable to legal liability due to high patient falls in the hospital’s Orthopedics and Bariatric department. Without proper fall prevention programs in place, accidents in hospitals like Mercy Medical Center are inevitable. Patients’ health should be the priority of any healthcare facility; hence incidents of accidents should be the least of hospitals’ problems. 

Other patient characteristics such as age, mental status, severe illness, and the use of ambulation aids also significantly contribute to falls due to the lack of enough healthcare providers at the facility. A policy that requires staff members at the hospital to be vigilant at all times will be successful if the patient-to-health providers’ ratio is balanced. According to the American Federation of Labor and Congress of Industrial Organizations (AFL-CIO), a balanced patient-to-nurse ratio is intertwined with positive healthcare outcomes – both patients and nurses experience success when a safe nurse staffing method is utilized (AFL-CIO, 2011).

Further, high workloads and lack of breaks between work shifts overwhelm healthcare providers to the extent they neglect patients that need close monitoring. Evidently, the prevalence of fall incidents at Mercy Medical Center calls for policy change at the facility, which will see the number of trained staff increase and accidents managed considerably. Patients’ recovery at health facilities depends on the presence of healthcare providers to monitor their progress and prevent possible accidents.

Mercy Medical Center serves a lot of Shakopee patients, with the majority, according to the 2017 U.S. Census, being Caucasians. On the contrary, about 85% of Mercy Medical Center staff are white (U.S. Census Bureau, 2017). Based on these statistics, opportunities for intercultural differences and miscommunication are enormous. Challenges associated with cultural views, linguistic limitations, and interaction can also be linked to the underperformance at Mercy Medical Center.

Therefore, fall prevention programs ought to be implemented in the hospital. In implementing the programs, members of staff should be trained on how strategies to utilize when handling culturally-diverse Shakopee residents. This will facilitate intercultural communication among diverse groups residing in Shakopee and the opportunity to better understand fall prevention strategies.

Policy and Practice Guidelines for Preventing Patient Falls at Mercy Medical Center Incidents of patient falls in hospitals, particularly Mercy Medical Center, pose a serious threat to patients’ health and the hospital’s legal responsibility. This policy will be a guide for healthcare practitioners at the hospital’s Orthopedics and Bariatric department to ensure incidents of patient accidents due to falls are contained. This policy will also apply to nurses and medical staff at medical centers and those working in community healthcare centers. In other words, it is directed to all persons responsible for prescribing and monitoring patient progress in hospitals.

Generally, falls prevention is a difficult and complex exercise. However, the most successful strategies and practices will include utilizing a standardized assessment tool that will identify fall and injury risk factors. The main tools for identifying risk factors for falls include the Morse Fall Scale and Hendrich II Fall Risk Model, integrated into all local, statewide, and national electronic medical record databases (Sentinel Event, 2015). 

This factor will be implemented in the medical centers to identify possible causes of falls within the facility. This policy proposes that the assessment tool will be a requirement enforceable by the federal government through health departments. In addition to the assessment tool, an interdisciplinary committee that will comprise a falls injury prevention task force will be formed to conduct visits across hospital premises to assess the status as per the federal government’s regulations.

A survey submitted to the Agency for Healthcare Research and Quality (AHRQ) showed that forming a team to assess and establish the capacity of a hospital’s organizational infrastructure and premises to mitigate injury risk from falls is essential (AHRQ, 2021). Every staff member at the hospital has a responsibility to play, as far as fall prevention is concerned. Primary care providers such as nurses, physicians, and factors such as environmental services, information technology, patient advocacy, pharmacy, physical and occupational therapy will also be incorporated in the assessment framework of the healthcare facility’s ability to alleviate injurious accidents caused by falls.

In line with the interdisciplinary team and establishing a comprehensive assessment tool, this policy also advocates increasing the number of trained staff in the community, state, and national hospitals. This will ensure that nurses and other healthcare providers do not experience burnouts, which is one of the primary contributors to patient negligence and ultimately accidents. Cornwall (2018) explains that workload and pressure experienced by hospital staff elevate burnout symptoms in the workplace.

Therefore the nurse-to-patient ratio in all healthcare facilities, primarily Mercy Medical Center, will adhere to the following ratio; 1:4 for the general medical-surgical ward, 1:3 for an emergency, and 1:2 for critical care units.

Effects Of Environmental Factors

The efficacy of the assessment tool established, the interdisciplinary team, and increasing the number of staff as an initiative to reduce patient falls will be affected by some environmental factors. Increased economic activities in Shakopee, such as industrialization, have significantly contributed to health complications to the residents. Remoundou and Koundouri (2009) explain that increased industrialization and energy use are the main drivers of environmental health problems. For example, an EPA report shows that the Brookhaven development southwest of Shakopee has raised nitrate levels in the water that exceed EPA limits (Sandvold, 2017). With such an intoxication to resources, the number of people visiting the facility keeps rising, which will further overwhelm staff working at the hospital even if the number is increased.

Stakeholder Involvement in Implementing Proposed Strategies

The success of the policy will heavily depend on staff members and the leadership at Mercy Medical Center’s readiness to embrace change. The interdisciplinary committee will comprise professionals from various healthcare facilities that are cognizant of relevant patient falls mitigation. Also, leaders such as directors of nursing will be important sources of data required to meet the recommended assessment criteria.