NHS-FPX6004 Assessment 2:Policy Proposal

Assessment 2: Policy Proposal

Infection prevention and control policies within organizations help improve the quality of care and prevent healthcare-acquired conditions (HACs). The Centers for Medicare and Medicaid Services (CMS) (2024) recognizes HACs as preventable events that healthcare organizations can prevent and control through risk management interventions like infection prevention and control programs. The benchmarking activities based on dashboard metrics demonstrated areas of underperformance that are critical to improving the efficacy of infection prevention and control policies in healthcare organizations. Consequently, this paper proposes policy and practice guidelines that will improve quality and performance associated with the benchmark underperformance based on the Centers for Disease Control and Prevention (CDC)’s Core infection prevention and control practices for safe healthcare delivery in all settings.

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Need for Policy and Practice Guidelines to Benchmark Metrics

Local, state, and federal health quality and efficiency metrics implore healthcare organizations to improve the responsiveness of their infection control programs as a part of risk mitigation measures. Creating policy and practice guidelines to address the shortfall in meeting the benchmark metrics on infection prevention and control is essential to meet federal policy guidelines like the Centers for Medicare and Medicaid Services’ value-based care and risk management, especially the reduction of healthcare-acquired conditions, which are preventable events yet can lead to adverse outcomes and negatively affect the quality of care.

Dashboard metric data showed that the facility had a 30% rate of infection for inpatients and 20% for outpatients. While the facility worked through its policy to reduce infection rates from 30% to below 5% across all areas, this metric remained higher than the national average for HACs, which is about 1% in every 100 patients. The benchmark underperformance affects the provision of quality care and organizational operations in various ways that include reduced patient safety levels, increased chances of adverse events that include healthcare-acquired conditions, and overall rise in the cost of care for patients and families (Sheehan et al., 2021). The underperformance also means that providers cannot offer quality care since they require more resources and must comply with best practice standards as mandated by professional entities like the American Nurses Association (ANA).

Possible repercussions of not implementing any changes include resource strain as CMS may not reimburse funds incurred in treating the affected patients due to preventable HACs, and poor patient safety levels. Without changes, the facility will not reduce, prevent, or mitigate possible adverse events like infections (Garcia et al., 2022). The current policy has improved patient care, enhanced staff motivation and performance, and lowered the cost burden related to infections, leading to the availability of resources for other purposes and activities. According to the Agency for Healthcare Research and Quality (AHRQ) (2023), organizations that implement infection prevention and control policies are likely to improve quality care and patient satisfaction levels. Again, missing required benchmarks leads to a rise in the cost of care, noncompliance with regulatory requirements, and violation of ethical principles in care provision, like beneficence, non-maleficence, and justice. Martinez (2024) asserts that performance metrics help organizations meet and improve patient safety needs, quality of care, and comply with legal and ethical requirements.

Summary of Proposed Organizational Policy and Practice Guidelines

The proposed policy targets the benchmark underperformance areas of standard precautions, leadership support, and performance monitoring and feedback. Effective leadership is essential, and the organization should develop a policy that implores leaders to support all quality improvement efforts that meet benchmarks and best practices in infection control and prevention (Garcia et al., 2022). For instance, the example of Parkland Health’s successful infection control policy demonstrates the critical role of leadership support.

The second aspect of this policy is the implementation of standard precautions as basic measures and practices to reduce the chances of infection spread. The facility, through its leadership, should develop an elaborate policy on infection prevention and control that entails strict adherence to standard practices like hand hygiene measures and regular risk assessment to determine areas for improvement. The policy also proposes regular audits and feedback from internal stakeholders and processes to inform areas for improvement and associated best practices that include hand hygiene, environmental cleanness, and activities to enhance quality and safe patient care delivery.

The policy and practice guidelines also propose surveillance to enhance root-cause analysis of infections and pathogen detection. The proposed policy addresses core federal healthcare provisions set through CMS requirements like value-based care, and CDC’s best practices to prevent and control infections in healthcare settings or organizations. Performance benchmarks set by CDC require organizations to develop guidelines in various areas of infection control and prevention as standard precautions to reduce and mitigate their prevalence at the organizational and professional level (CDC, 2024). Additionally, the American Hospital Association (AHA) (2025) asserts that infection prevention and reduction are long-term quality and patient safety priorities that require more attention and resource allocation by healthcare entities. Therefore, the association implores healthcare entities to develop, implement, and monitor robust infection control and prevention measures and allocate sufficient resources to addressing their occurrence. As such, best practices and guidelines are imperative to address infections and reduce their adverse effects on patient care outcomes.

Potential Effects of Environmental Factors on Recommended Practice Guidelines

Environmental factors may impact the implementation of the recommended practice guidelines to lower and control infections. For example, training and retooling of nurses to implement these guidelines, leadership support, and having sufficient resources to carry out regular surveillance present possible hurdles within the setting. Effective infection surveillance requires nurses and other professionals to possess skills and capabilities that only become available after training and education (Martinez, 2025). Again, support from leadership in the organization is an environmental aspect that can enhance the implementation of the recommended practice guidelines to reduce infections in the facility. Additionally, funding challenges within the environment and possible resistance to change are potential environmental factors that may negatively affect the recommended practice guidelines.

Regulatory considerations like the value-based care model and patient care quality requirements by the Affordable Care Act and the Centers for Medicare and Medicaid Services (CMS) may impact the recommended guidelines as they require sufficient funding and meeting benchmark metrics set by federal agencies. Regulatory considerations based on policies like HIPAA may curtail surveillance and information sharing based on their privacy and confidentiality requirements. Additionally, resource allocation, like sufficient staffing, financial support, and support services, may impact the implementation of the recommended guidelines. For instance, conducting all aspects of the policy and guidelines requires more staff, including support services and leadership support. These components may not be available in the organization, leading to ineffective implementation of the proposed policy changes.

Ethical, Evidence-Based Practice Guidelines, & Impact of Proposed Changes

Ethical and evidence-based practice guidelines will be critical to improve the targeted benchmark performance. The ethical approach in this case requires providers and the organization to uphold ethical values like beneficence, autonomy, and non-maleficence. Respect for the inherent dignity of different stakeholders is also essential, as it improves observation of values like transparency and honesty, and develops trust in the proposed interventions, leading to more support from organizational leaders (Tan et al., 2023). Ethical training and systematic integration of best practices based on evidence will increase the effectiveness of the proposed infection control and prevention practice guidelines in the facility.

In their study, Sheehan et al. (2021) suggest that facilities can enhance performance for the targeted benchmark through effective collaboration and communication by organizational leaders, engagement and participation of all stakeholders, especially internal stakeholders like employees, and continuous monitoring and feedback to detect any areas for improvement. Further, leadership support and systematic integration of best practices, especially standard precautions, will enhance the performance of the targeted benchmarks of reducing infections to less than the national rate. These strategies will ensure the performance improvement and compliance with existing healthcare laws and policies as they will increase awareness, suggest the best ways to attain compliance levels, and improve coordination and collaboration (Garcia et al., 2022). For instance, CMS and CDC’s infection control measures are elaborate and aimed at improving patient safety and quality of care. Therefore, these strategies are based on best practices in the industry and can be customized for optimal care attainment for diverse patient populations.

Ethical strategies are founded on their alignment with proposed ethical provisions like respect for patient dignity and honest interactions leading to increased trust levels among healthcare providers and patients (Tan et al., 2023). To ensure that the strategies are ethical and culturally inclusive in their application, the organizational leaders will work collaboratively with all stakeholders and adhere to the code of ethics as established by professional organizations like the American Nurses Association.

These changes will have a significant impact on stakeholders’ work settings and job requirements. Firstly, nurses will require more training, especially targeted training, while organizational leaders will develop collaborative approaches to ensure the attainment of reduced infections and improvement in patient care outcomes (Garcia et al., 2022). Secondly, stakeholders like patients will develop a collaborative approach to care where they will interact with nurses and other healthcare providers to reduce infections through hand hygiene measures. Thirdly, these changes will require stakeholders to redesign their work settings due to new practices that will be established to control infections. Therefore, the proposed changes will have a significant impact on various stakeholders within the facility.

Stakeholders and Groups in developing and implementing proposed policy and practice guidelines

The core stakeholders in the proposed policy initiative include patients, the management, healthcare providers, regulatory agencies, and the general public. These stakeholders play and will play different roles in the attainment of the proposed policy, as demonstrated by their inclusion. For instance, the proposed policy and practice guidelines aim to improve infection control and prevent possible infections among patients in the facility. The management will provide resources and support to implement the proposed interventions, while providers will be executors of the different aspects to control and prevent infections. Therefore, the participation and engagement of all stakeholders underscores the critical role they play in controlling and preventing adverse events, including infections in healthcare facilities and settings. The participation will produce a robust policy and facilitate its implementation because of the diverse and unique perspectives and input they will provide to the team. As noted by Khatib et al. (2022), the involvement, participation, and engagement of these stakeholders will create a robust policy since all will be accountable for their decisions and actions, or lack thereof. The implication is that these stakeholders will evaluate the program and recommend its effectiveness for long-term systematic integration into standard and routine practices and processes within the facility.

Collaboration Strategies

Collaboration among stakeholders is essential for the attainment of the infection control and prevention program in the facility. As such, the collaboration strategies in this case would include community outreach programs, mentorship programs for those in medical and nursing schools, and role assignment. For instance, by giving or delegating roles to different stakeholders, the facility will benefit from their expertise, leading to quality care outcomes. The stakeholders, like community leaders, will distribute and disseminate information on quality control measures at the facility with other members in their communities (Sheehan et al., 2021). Other stakeholders, like nurses and physicians, will use their expertise to develop and implement effective practices while encouraging others to integrate them into their routine activities. The inclusion of stakeholder groups like nurses and physicians, as well as community leaders, and their collaboration is critical to the successful implementation of the policy, as it means more will accept and prioritize these interventions with limited or no change resistance. Collaboration will be critical for broad-based input and delegation of responsibilities to various stakeholders based on their competence and experience.

Conclusion

Infections continue to be a health concern due to their adverse effects, including comorbidities and poor care outcomes. As such, infection control and prevention policies and best practice guidelines are essential to reduce rates of infection and meet performance benchmarks and ethical requirements for better care. The proposed policy and practice guidelines on infection control will help the organization to reduce the infection rate and meet national and regulatory requirements. These guidelines help facilitate the prompt implementation of infection control and prevention measures in healthcare facilities and organizations. These policies and evidence-based practice guidelines promote safe and quality patient care and increased satisfaction of healthcare providers.

References

American Hospital Association (AHA) (2025). Infection Control and Prevention.

https://www.aha.org/infection-control-and-prevention

Centers for Medicare and Medicaid Services (CMS) (2025 August 6). Hospital-Acquired

Condition Reduction Program.

https://www.cms.gov/medicare/quality/value-based-programs/hospital-acquired-conditions

Agency for Healthcare Research and Quality. (AHRQ) (2023). National Healthcare Quality and

Disparities Report. https://www.ahrq.gov/research/findings/nhqrdr/index.html

Centers for Disease Control and Prevention (CDC) (2024, April 12). CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings.

https://www.cdc.gov/infection-control/hcp/core-practices/index.html

Garcia, R., Barnes, S., Boukidjian, R., Goss, L. K., Spencer, M., Septimus, E. J., … & Levesque, M. (2022). Recommendations for change in infection prevention programs and practice. American journal of infection control, 50(12): 1281-1295. https://doi.org/10.1016/j.ajic.2022.04.007

Khatib, M. E., Kherbash, A., Qassimi, A. A., & Mheiri, K. A. (2022). How can collaborative

work and collaborative systems drive operational excellence in project management?

Journal of Service Science and Management, 15(03), 297–307.

https://doi.org/10.4236/jssm.2022.153017

Martinez, W. (2025). From insight to action: tackling underperformance in health professionals. BMJ Quality & Safety, 34(2): 77-80. https://doi.org/10.1136/bmjqs-2024-017682

Parkland Health (n.d.). Hospital-Acquired Infections.

https://www.parklandhealth.org/hospital-acquired-conditions

Sheehan, J., Laver, K., Bhopti, A., Rahja, M., Usherwood, T., Clemson, L., & Lannin, N. A.

(2021). Methods and effectiveness of communication between hospital allied health and

primary care practitioners: A systematic narrative review. Journal of Multidisciplinary

Healthcare, 14(14): 493–511.

Tan, C., Ofner, M., Candon, H. L., Reel, K., Bean, S., Chan, A. K., & Leis, J. A. (2023). An

ethical framework adapted for infection prevention and control. Infection Control &

Hospital Epidemiology, 44(12): 2044-2049. DOI: 10.1017/ice.2023.121

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In advocating for institutional policy changes related to local, state, or federal healthcare 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 healthcare. This assessment offers you an opportunity to take the lead in proposing such changes.

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

Instructions

Propose an 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.

Requirements

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.
Use paraphrasing and summarization to represent ideas from external sources.
- Be sure to apply correct APA formatting to source citations and references.

Policy Proposal Format and Length

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

Supporting Evidence

Cite 3–5 references to current and scholarly research, case studies, or best practice guidelines to support your analysis and recommendations.

Competencies Measured

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

Competency 1: Analyze relevant healthcare laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
- Explain and interpret for stakeholders 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.
Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
- Summarize a proposed organizational policy or practice change guideline and analyze the potential effects of environmental factors on recommended practice guidelines.
Competency 3: Evaluate relevant indicators of performance, such as benchmarks, research, and best practices, to inform healthcare laws and policies for patients, organizations, and populations.
- Explain how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change.
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 or practice change to improve quality and outcomes.
- Present strategies for collaborating with a stakeholder group to implement 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.
- Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.

Explain and interpret for stakeholders 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.

Distinguished

Explains to stakeholders 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. Clearly articulates the effects of benchmark underperformance and draws sound conclusions about the potential repercussions of inaction, based on credible evidence and relates information to stakeholder group.

Proficient

Basic

Identifies to stakeholders 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. irrespective of a particular need.

Non Performance

Does not explain to stakeholders 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.

Criterion 2

Summarize a proposed organizational policy or practice change guideline and analyze the potential effects of environmental factors on recommended practice guidelines.

Distinguished

Succinctly summarizes a proposed organizational policy and practice guidelines; analyzes the potential effects of environmental factors on recommended practice guidelines. Identifies clear cause-and-effect relationships and the influence of those factors on specific recommendations.

Proficient

Summarizes a proposed organizational policy and practice change guidelines and the potential effects of environmental factors on recommended practice guidelines.

Basic

Provides a summary that paints an unclear picture of a proposed organizational policy and practice guidelines and/or does not expand on environmental factors that can affect recommended practice guidelines.

Non Performance

Does not summarize a proposed organizational policy and practice guidelines or identify environmental factors that can affect recommended practice guidelines.

Criterion 3

Explain how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change.

Distinguished

Explains how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change. Provides clear and compelling justification, substantiated by credible evidence.

Proficient

Basic

Identifies how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change but does not provide context or rationale to support the content.

Non Performance

Does not explain how ethical, evidence-based practice guidelines to improve targeted benchmark performance will impact a stakeholder group needed for successful implementation of the policy or practice change.

Criterion 4

Explain why particular stakeholders and groups must be involved in further development and implementation of a proposed policy or practice change to improve quality and outcomes.

Distinguished

Provides a perceptive and succinct explanation of why particular stakeholders and groups must be involved in further development and implementation of a proposed policy and practice guidelines. Offers clear and convincing rationale for stakeholder and group engagement and how it strengthens policy and facilitates changes in practice to improve quality outcomes.

Proficient

Explains why particular stakeholders and groups must be involved in further development and implementation of a proposed policy and practice guidelines change to improve quality and outcomes.

Basic

Identifies stakeholders and groups who are not the most logical choices to be involved in further development and implementation of a proposed policy and practice guidelines and implementation of a proposed policy or practice change to improve quality and outcomes.

Non Performance

Does not explain why particular stakeholders and groups must be involved in further development and implementation of a proposed policy or practice change to improve quality and outcomes.

Criterion 5

Present strategies for collaborating with a stakeholder group to implement a proposed policy and practice guidelines.

Distinguished

Presents strategies for collaborating with a stakeholder group to implement a proposed policy and practice guidelines. Makes a compelling case for the importance of stakeholder collaboration and considers stakeholder perspectives by addressing possible objections.

Proficient

Presents strategies for collaborating with a stakeholder group to implement a proposed policy and practice guidelines.

Basic

Presents stakeholder collaboration strategies for implementing a proposed policy and practice guidelines that lack clear relevance or insight into the positions and perspectives of the stakeholder group.

Non Performance

Does not present strategies for collaborating with a stakeholder group to implement a proposed policy and practice guidelines.

Criterion 6

Organize content so ideas flow logically with smooth transitions.

Distinguished

Organizes content so clarity is enhanced and all ideas flow logically with smooth transitions.

Proficient

Organizes content so ideas flow logically with smooth transitions.

Basic

Organizes content with some logical flow and smooth transitions.

Non Performance

Does not organize content for ideas to flow logically with smooth transitions.

Criterion 7

Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.

Distinguished

Supports main points, assertions, arguments, conclusions, or recommendations with relevant, credible, and convincing evidence. Skillfully combines virtually error-free source citations with a perceptive and coherent synthesis of the evidence.

Proficient

Supports main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.

Basic

Sources lack relevance or credibility, or the evidence is not persuasive or explicitly supportive of main points, assertions, arguments, conclusions, or recommendations.

Non Performance

Does not support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.