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CAPELLA FPX 8030-5 ; Assessment 5 Instructions: Creation of Policy or Procedure

CAPELLA FPX 8030-5 ; Assessment 5 Instructions: Creation of Policy or Procedure


  • Create a new policy for the medical center based on evidence using the attached Hospital Policy template.


    Quality improvement begins with the end in mind. Up until now, you have researched the practice problem and developed a focused, evidence-based intervention to address a patient safety problem. The next step would be to implement the practice change and evaluate the change to determine the effect it had on the population. Now, developing a policy will help sustain the change.

    Along the way, you will learn that as a leader in a health care organization, you will not only facilitate the steps of evidence-based practice, but you will apply evidence-based leadership strategies to serve as a role model for decision making in your organization. Your skills and ability to promote and encourage evidence-based behavior and decision making among staff, providers, and other leaders will be invaluable to creating and sustaining an evidence-based organization and a culture of evidence. Your own leadership style will influence how you support and model evidence-based processes at your organization.


    The purpose of this assessment is to complete the stages in the EBP process, translating the research into practice. You will be developing a policy or procedure to address a patient safety issue in a healthcare setting. Incorporate information from prior assessment where appropriate.


    As the Director of Clinical Operations and Nursing Excellence, it is your responsibility to ensure that the best practices and protocols are implemented and sustained at the medical center. The next step is to translate the evidence into practice. Policy development is an important final step. Without a formal policy or guideline, it is likely the change will not become permanent. Policies and procedures standardize care which in turn, improves patient safety.


    Create a new policy for the medical center based on evidence, using the 

    1. Review the template before you begin filling in each section, and gather any materials or documentation you will need.
    2. In the Subject/Title of Policy section of the type the name of the policy.
    3. In the Purpose section, explain the purpose of the policy in 1-2 short paragraphs. Include the following:
      • Summarize the patient safety issue.
        • Explain the gap or a problem in a health care or public health situation that caused the issue.
      • Use supporting evidence from the literature to show how it determined the need.
        • Explain how the evidence was gathered.
      • Include your revised PICO(T) question.
      • Explain why it was necessary to take action with the development of this policy.
    4. In the Population Affected by the Policy section, identify and describe the populations affected by the change and how the scope of the problem was determined.
      • Scope is the extent of the problem, or how wide-sweeping the issue is for the target population and the community.
      • Describe the target population to be addressed by an intervention in enough detail that it is clear what population is included or excluded.
    5. In the Definitions section, create definitions that explain the industry specific terms used throughout the document needed for the understanding of the policy.
      • Explain the terms in a manner that is descriptive to non-industry personnel.
    6. In the Policy Statement section, create a policy statement in a 3-5 sentence paragraph that includes the following:
      • State the organization's declaration of the plans giving a timeframe and scope of the policy implementation.
      • Explain the organization's intentions or goal regarding the patient safety issue.
      • Clearly describe the policy plans, explaining that this is a quality improvement project based on evidence-based practices to address a specific patient safety issue.
    7. In the Procedure section, elaborate on the step-by-step procedure that was outlined in the policy statement above in enough detail that one could replicate the process based on your description alone.
      • Information needs to be clear and easy to read. Avoid using wordy paragraphs.
      • Describe all the processes involved. This section could be in a numbered list or a detailed flowchart. Include the following:
        • All participants with their specific responsibilities listed.
        • Step-by-step description of the logistical flow of how the policy is to be implemented.
        • Instructions for completing each step.
        • A

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