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 healthcare policies or laws. Use your topic from Assessment 1 to complete this.
- What is the current benchmark for the organization and the numeric score for underperformance?
- How is the benchmark underperformance affecting the provision of quality care or the organization’s operations?
- What are the potential repercussions of not making any changes?
- What evidence supports your conclusions?
- Summarize your proposed organizational policy and practice guidelines.
- Identify applicable local, state, or federal healthcare policy or law that prescribes relevant performance benchmarks that your policy proposal addresses (using your Advocacy Issues topic from the AHA).
- Keep your audience in mind when creating this summary statement.
- 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 ethical, evidence-based practice guidelines to improve targeted benchmark performance and the impact the proposed changes will have on the targeted group.
- 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 healthcare policy or law?
- How can you ensure that these strategies are ethical and culturally inclusive in their application?
- What is the direct impact of these changes on the stakeholders’ work setting/job requirements?
- 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?
- Present strategies for collaborating with the stakeholder group to implement your proposed policy and practice guidelines.
- What role will the stakeholder group play in implementing your proposal?
- Why is the stakeholder group and their collaboration important for successful 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.
Struggling with where to start this assignment? Follow this guide to tackle it easily!
Step 1: Explain the Need for Policy
1. Identify the Benchmark Shortfall
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Topic: Labor and Delivery – Maternal Hemorrhage Prevention
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Current Benchmark: 90% of laboring patients receive hemorrhage risk assessment within 1 hour of admission.
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Underperformance: Only 75% compliance.
2. Impact of Underperformance
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Delays in identifying high-risk patients can lead to:
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Increased maternal morbidity or mortality
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Higher likelihood of complications (blood transfusions, ICU admission)
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Negative effect on hospital quality scores and accreditation metrics
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3. Potential Repercussions of Inaction
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Legal: Liability for malpractice claims due to preventable adverse outcomes
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Ethical: Breach of duty to provide safe, timely care
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Financial: Increased costs from complications, extended hospital stays, and CMS penalties
4. Supporting Evidence
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Joint Commission: National Patient Safety Goal NPSG.06.01.01 requires timely identification of hemorrhage risk.
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Florida Department of Health: Maternal health guidelines emphasize early risk assessment and intervention.
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Studies show early hemorrhage risk identification reduces maternal morbidity by 20–30% (ACOG, 2022).
Speaker Notes Example:
“Current compliance gaps in maternal hemorrhage assessment highlight the urgent need for organizational policy to standardize risk assessment and improve patient safety outcomes.”
Step 2: Summarize Proposed Policy and Guidelines
Policy Proposal:
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Implement a mandatory hemorrhage risk assessment protocol for all laboring patients within 1 hour of admission.
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Develop practice guidelines for monitoring, rapid intervention, and documentation.
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Integrate risk assessment into the EMR as a required field.
Applicable Policies and Laws:
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Joint Commission NPSG on maternal hemorrhage
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CMS Core Measures for obstetric care
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Florida Statutes on hospital patient safety and quality standards
Speaker Notes Example:
“The policy aligns with national, state, and federal guidelines, ensuring timely care while meeting regulatory benchmarks and improving maternal outcomes.”
Step 3: Environmental and Regulatory Considerations
1. Environmental Factors:
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High patient volume and diverse population in Miami L&D units
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Language and cultural barriers impacting patient education and compliance
2. Regulatory Considerations:
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Joint Commission accreditation standards
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CMS reporting requirements for maternal health outcomes
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State reporting requirements for maternal mortality and morbidity
3. Resource Considerations:
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Staffing: Adequate L&D nurse-to-patient ratios for timely assessment
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Financial: EMR upgrades and staff training budgets
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Logistical: Rapid response protocols and availability of blood products
Speaker Notes Example:
“Successful implementation depends on balancing regulatory compliance with available staffing and resources while addressing the needs of a diverse patient population.”
Step 4: Ethical and Evidence-Based Practice Guidelines
Evidence-Based Strategies:
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Standardized risk assessment checklists at admission
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Interprofessional team simulation drills for hemorrhage management
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Continuous data tracking and feedback to monitor compliance
Ensuring Compliance and Ethics:
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Policies follow evidence-based guidelines (ACOG, 2022) and are culturally inclusive
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Use translators and patient education materials in multiple languages
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Protect vulnerable populations while improving quality of care
Impact on Stakeholders:
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L&D nurses: clear assessment expectations and workflow integration
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Physicians: timely alerts for high-risk patients
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Hospital leadership: improved quality metrics and reduced liability
Speaker Notes Example:
“Integrating evidence-based strategies ensures ethical, equitable care, aligns with policy, and reduces preventable maternal complications.”
Step 5: Stakeholder Involvement
Key Stakeholders:
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L&D nurses, obstetricians, anesthesiologists
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Hospital quality improvement (QI) team
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IT/EMR specialists
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Patient advocates
Importance of Engagement:
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Ensures buy-in and practical input from staff who implement policy
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Strengthens adoption and sustainability
Speaker Notes Example:
“Engaging frontline staff and leadership ensures the policy is feasible, culturally sensitive, and sustainable.”
Step 6: Collaboration Strategies
Implementation Strategies:
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Form interprofessional policy committee to oversee adoption
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Conduct training sessions and simulation drills
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Use real-time dashboards for compliance monitoring
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Regularly review metrics and adjust protocols as needed
Stakeholder Roles:
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Nurses: perform risk assessments
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Physicians: verify high-risk cases and intervene
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QI team: track metrics and report performance
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IT: maintain EMR workflow and alerts
Speaker Notes Example:
“Collaboration across stakeholder groups ensures the policy is fully implemented, monitored, and continuously improved to meet benchmarks.”
Step 7: Organization and Presentation
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Ensure content flows logically from problem identification to solution.
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Use clear headings for each section.
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Proofread for grammar, clarity, and APA-style citations.
Sample References (APA 7th Edition):
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American College of Obstetricians and Gynecologists. (2022). Prevention and management of postpartum hemorrhage. https://www.acog.org
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Joint Commission. (2023). National Patient Safety Goals. https://www.jointcommission.org/standards/national-patient-safety-goals/
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Centers for Medicare & Medicaid Services. (2022). Hospital quality initiatives. https://www.cms.gov
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Florida Department of Health. (2021). Maternal health guidelines. https://www.floridahealth.gov
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