Use the TEMPLATE ATTACHED to complete this assessment.
- 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. ( LABOR AND DELIVERY NURSE)
- 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. ( MIAMI , FLORIDA MY AREA)
2. Policy Application: Find a policy, set of guidelines, or government regulations and apply it to the organization’s 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.
3. 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.
- 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 benchmark’s numerical value.
- Parkland Health: Preventive Care 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.
- 4. 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.
- Be sure to clearly identify implications and acknowledge assumptions underlying your analysis.
5.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.
Struggling with where to start this assignment? Follow this guide to tackle it easily!
Step 1: Topic Selection
1. Identify a Topic:
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Focus on a Labor and Delivery Nursing concern in your organization or area.
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Example: Preventing Maternal Hemorrhage in Labor and Delivery Units.
2. Context:
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Miami, FL has high birth rates with diverse populations, including Hispanic and Haitian communities.
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Maternal hemorrhage is a leading cause of maternal morbidity and mortality, making it a priority area for quality improvement.
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Use American Hospital Association (AHA), Joint Commission National Patient Safety Goals (NPSG), or Centers for Medicare & Medicaid Services (CMS) as references for best practices.
Speaker Note Example:
“Maternal hemorrhage remains one of the top contributors to maternal morbidity nationally. Focusing on prevention in the L&D unit aligns with CMS and Joint Commission standards and improves patient outcomes in Miami’s diverse population.”
Step 2: Policy Application
1. Identify a Relevant Policy:
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Example: Joint Commission NPSG.06.01.01 – Reduce the risk of patient harm resulting from hemorrhage during childbirth.
2. Compliance and Law:
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Policy aligns with Federal Patient Safety and Quality Improvement Act and Florida Statutes on maternal health and safety standards.
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Evidence: Hospitals are required to implement risk assessments, hemorrhage protocols, and rapid response systems.
3. Implications of Non-Compliance:
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Legal: Risk of malpractice or state/federal sanctions.
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Ethical: Harm to patients and breach of duty of care.
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Financial: Increased costs due to readmissions, complications, or litigation.
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Impacted stakeholders: nurses, physicians, hospital leadership, and patients.
Speaker Note Example:
“Non-compliance could lead to serious ethical, legal, and financial consequences. Adhering to hemorrhage prevention protocols protects both patients and the organization from avoidable harm.”
Step 3: Benchmark Comparison
1. Select Benchmark:
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Example: Target: 90% of laboring patients receive hemorrhage risk assessment within 1 hour of admission.
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Source: CMS Core Measures / Joint Commission Recommendations
2. Compare Policy vs. Benchmark:
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Current metric: only 75% compliance in your L&D unit.
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Gap: 15% of patients not assessed timely, putting them at risk.
Speaker Note Example:
“Benchmarking against the Joint Commission goal highlights a significant compliance gap, underscoring the need for intervention.”
Step 4: Metric Analysis
1. Identify Needed Changes:
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Develop or revise risk assessment tools.
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Implement staff education and competency checklists.
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Introduce real-time reporting dashboards for unit managers.
2. Interprofessional Education (IPE) Team Plan:
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Collaborate with nurses, OB physicians, anesthesiologists, and quality officers.
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Example action: weekly review of missed risk assessments and rapid corrective measures.
3. Consequences of Not Meeting Benchmark:
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Increased maternal morbidity and mortality
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Poor quality scores and reputational risk
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Potential loss of accreditation
Speaker Note Example:
“A multidisciplinary team approach ensures accountability and rapid improvement in meeting benchmarks for patient safety.”
Step 5: Sustainability and Ethics
1. Sustainability Measures:
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Embed risk assessment into EMR as mandatory fields.
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Continuous staff training and audit cycles.
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Feedback loops with monthly QI reports.
2. Ethical Considerations:
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Ensure all patient populations, including vulnerable groups, receive equitable care.
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Policies must protect cultural and language differences in Miami’s diverse community.
3. Advocacy:
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Present QI plan to stakeholders emphasizing ethical obligation, regulatory compliance, and improved maternal outcomes.
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Use data-driven arguments for sustainable funding and staffing.
Speaker Note Example:
“By ensuring sustainability and ethical practice, the plan not only meets benchmarks but also aligns with professional nursing standards and protects diverse patient populations.”
References (APA 7th Edition Examples)
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American Hospital Association. (2023). Quality and patient safety initiatives. https://www.aha.org
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Centers for Medicare & Medicaid Services. (2022). Hospital quality initiatives. https://www.cms.gov
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Joint Commission. (2023). National Patient Safety Goals. https://www.jointcommission.org/standards/national-patient-safety-goals/
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Florida Department of Health. (2021). Maternal health and safety guidelines. https://www.floridahealth.gov
Next Step: Use this framework to populate the template attached for your assignment. Fill in each section with:
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Your selected topic
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Relevant policy and benchmark
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Metrics analysis with QI plan
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Sustainability and ethical considerations
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