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Policy Proposal
Brittany Leese
Capella University
Health Care Law and Policy
June 2022
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Policy Proposal
Mercy Medical Centers is one of the region’s top choices for the highest quality health
care. While being ranked in the top, there is always room for improvement to better serve the
community. The diabetic patient population that chooses care at Mercy Medical Center are not
receiving the highest quality of care, based on national benchmarks. Throughout this paper there
will be discussion on the need for a change in policy and practice guidelines. The environmental
factors on implementation and the need for key stakeholders to be involved to have successful
implementation will also be reviewed.
Need for Policy and Practice Guidelines
Diabetes is the leading cause of morbidity and mortality in the United States and the use
of preventative screenings limits complications and can improve health outcomes (Marino et al.,
2020). There is a standard national benchmark set forth to determine what is appropriate for the
diabetic population to be receiving a foot examination on at least and annual basis, this goal is 84
percent (NHQDR Web Site – National Diabetes Benchmark Details, n.d). The screenings
completed at Mercy Medical Center were on average of 58 percent completion for the years
2019 and 2020, this is significantly below an acceptable level of care provided to the diabetic
population in which it serves. Mercy Medical Center claims to provide top quality care, but there
is an obvious disconnect in need of addressing to provide better care for their patients.
The diabetic population often suffers from peripheral neuropathy and peripheral artery
disease, both of which affect the sensations felt in the distal extremities (Buschkoetter, 2019).
This increases the risk of unknown injuries or wounds sustained to the foot and becomes the
starting point for long-term complications for the patient. Due to the poor blood flow, it often
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takes the wounds on a diabetic foot a significantly longer time to heal, or some that never heal
and remain a chronic worry for the patient. It is reported that one third of the financial burdens of
caring for diabetic patient is related to the cost of caring for foot wounds, ulcers, and amputations
(Kurkela et al., 2022). Not only is this significant from a financial standpoint, but the quality of
life of those affected by diabetic foot complications or amputation is affected. It has been
determined that the completion of a comprehensive foot exam to evaluate for wounds, as well as
sensation, has been deemed beneficial for reducing the occurrence of diabetic wounds and ulcers
and should be an adopted practice by healthcare providers (Buschkoetter, 2019).
Policy and Practice Guidelines for Diabetic Foot Examinations
Policy Statement
Diabetic foot examinations are imperative to the care of the diabetic patient population.
This policy is intended to guide healthcare providers in ensuring completion of a foot
examination, including physical appearance and sensation, is completed annually during routine
visits. The practice guidelines will provide recommendations on how to best complete routine
foot examinations, as well as how to provide education to patients to complete self-exams at
home.
Scope
This policy applies to the healthcare providers, that includes and is not limited to:
medical doctor, doctor of osteopathic medicine, nurse practitioner, physician assistant and
nursing staff. All included are responsible and capable of completion of a foot examination on an
annual basis or more frequently for higher-risk patients, as well as providing patient education
for self-care at home.
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Practice Guidelines
It is at the guidance of the American Diabetes Association (ADA), there are some
guidelines already recommended for caring for the diabetic patient in regards to their foot exams.
The expectation is that each time a patient is evaluated in the office, regardless of the reason of
visit, the patients’ feet should be inspected for deformities or wounds, sensation, and vascular
blood flow (Syed, 2021). By completing this basic assessment, the healthcare provider will be
able to identify any existing foot wounds, or the risk of development of wounds. The diabetic
patients who have other comorbidities that make them high-risk, such as dialysis, smoking, or
previous history of a diabetic wound, will need to be monitored more closely and referral to a
foot specialist is recommended, as a multidisciplinary approach is best practice for this patient
population (Syed, 2021).
The recommendation by the ADA is that general preventative foot self-care education
should be provided to all diabetic patients during their visits (Syed, 2021). There were more
specific guidelines established by the International Working Group of the Diabetic Foot that will
be incorporated into the practice guidelines. It will be the duty of the healthcare provider
evaluating the diabetic patient to ensure to educate the patient on preventative care for their feet,
between visits. Topics to be discussed with the patients who are at risk for foot wounds are to
include: protect the feet by not going barefoot, inspect the inside of the shoe prior to application,
perform a daily evaluation of the foot surface and between the toes, washing the feet daily and
ensuring to dry thoroughly, cut toenails straight across-if unable to perform, seek professional
assistance with cutting nails, and encourage the patient to notify healthcare team if an
abnormality is found immediately to have it evaluated and treated (Bus et al., 2020). These items
can be discussed with the patient, family members, or caregivers that assist with activities of
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daily living during each visit and also could be provided to them in a handout form to reference
while at home, to continue self-care practices. It is not enough to review the self-care
examination with the patient, family member, or caregiver, it is also necessary to stress the
importance of completing it to prevent debilitating side effects from foot wound development
(Retinopathy, Neuropathy, and Foot Care: Standards of Medical Care in Diabetes—2022, 2021).
Effects of Environmental Factors
In the state of Minnesota, where Mercy Medical Center is, 390,00 patients were
diagnosed with diabetes, with an estimated 24,000 new cases each year (Diabetes in Minnesota –
Minnesota Department of Health, 2022). The sheer volume alone of those affected by diabetes is
concerning for a potential environmental fact that can hinder successful implementation of the
change in practice. To allow for enough time to for the healthcare provider to evaluate the
patient’s foot and also provide education to them about self-care, in a manner that they
comprehend, can consume a significant amount of time allotted for the visit. The other area of
concern is, are there physically enough healthcare providers available to manage that volume of
diabetic patients. There has been a shortage in the healthcare workforce since the COVID-19
pandemic due to burnout and retirement, and the recruitment to recover from the loss in
healthcare workers has become a concern as well (Health Worker Shortage Forces States to
Scramble, 2022). With the volume of patients increasing and the healthcare workers available to
care for them being at a mismatched level, it is worrisome that the ability to provide patients the
care they deserve will continue to suffer. In order to best manage the shortage of healthcare
workers, it is imperative that the education of self-care for foot examinations and preventative
care is necessary to prevent diabetic complications (Portela et al., 2022). The preventative visits
that are occurring will still need to have the comprehensive foot exam completed on an annual
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basis, but the patient’s taking responsibility for their own care will assist them in reducing
potential foot wounds.
Stakeholder Involvement in Implementation
The successful implementation of this change in practice will fall into the hands of the
key stakeholders. Those stakeholders are the medical doctors, doctors of osteopathic medicine,
physician assistants, nurse practitioners, and the nursing staff. They are the responsible parties
for completing the comprehensive annual foot examinations. The healthcare providers mentioned
above are also educators for the patients, to teach patients the knowledge of caring for
themselves at home by performing self-examinations daily (Bus et al., 2020). This information
should also be provided to the patients in a simple handout format so the patients can refer to it at
home, when completing their daily foot exam, until it becomes a learned habit. Should there be
difficulties with completion of the examinations by the healthcare providers, or patients that are
more high-risk cases, they should be referring the patient to a foot specialist to ensure the patient
is receiving the proper examination (Syed, 2021). The ultimate goal is to be providing the
diabetic patients the basic preventative care they deserve, while also encouraging them to be self-
empowered to care for themselves with their chronic condition.
Conclusion
In order to ensure that quality care is being provided to diabetic patients, national
benchmarks have been established to set the standards of care. The patients at Mercy Medical
Center have not been receiving the care they are deserving of and to better serve them, there is a
change in practice being implemented. The healthcare providers will be performing annual foot
examinations on every diabetic patient that they see and they will be providing the patient with
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the necessary education to perform a self-examination at home, between visits. It is recognized
that the healthcare work force is in shortage, but it is not justification to not provide the
necessary care to the diabetic population, but rather all the more reason to encourage self-
examinations performed by the patients. It is with high hopes that by changing the practice
guidelines there will be increased quality of care and decreased foot wounds in the patients cared
for by Mercy Medical Center.
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References
Bus, S. A., Lavery, L. A., Monteiro‐Soares, M., Rasmussen, A., Raspovic, A., Sacco, I. C., &
Netten, J. J. (2020). Guidelines on the prevention of foot ulcers in persons with diabetes
(IWGDF 2019 update). Diabetes/Metabolism Research and Reviews, 36(S1).
https://doi.org/10.1002/dmrr.3269
Buschkoetter, K. L. M. (2019). Implementation of a comprehensive diabetic foot exam protocol
in rural primary care. Online Journal of Rural Nursing and Health Care, 19(1), 43–63.
https://doi.org/10.14574/ojrnhc.v19i1.560
Diabetes in minnesota – minnesota department of health. (2022, February). Minnesota
Department of Health. Retrieved June 1, 2022, from
https://www.health.state.mn.us/diseases/diabetes/data/diabetesfacts.html
Health worker shortage forces states to scramble. (2022, March 25). The Pew Charitable Trusts.
Retrieved June 1, 2022, from https://www.pewtrusts.org/en/research-and-
analysis/blogs/stateline/2022/03/25/health-worker-shortage-forces-states-to-scramble
Kurkela, O., Nevalainen, J., Arffman, M., Lahtela, J., & Forma, L. (2022). Foot-related diabetes
complications: Care pathways, patient profiles and costs. BMC Health Services Research,
22(1). https://doi.org/10.1186/s12913-022-07853-2
Marino, M., Angier, H., Springer, R., Valenzuela, S., Hoopes, M., O’Malley, J., Suchocki, A.,
Heintzman, J., DeVoe, J., & Huguet, N. (2020). The affordable care act: Effects of
insurance on diabetes biomarkers. Diabetes Care, 43(9), 2074–2081.
https://doi.org/10.2337/dc19-1571
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Portela, R. D. A., Silva, J. R. S., Nunes, F. B. B. D. F., Lopes, M. L. H., Batista, R. F. L., & Silva,
A. C. O. (2022). Diabetes mellitus type 2: factors related to adherence to self-care.
Revista Brasileira de Enfermagem, 75(4). https://doi.org/10.1590/0034-7167-2021-0260
Retinopathy, neuropathy, and foot care: Standards of medical care in diabetes—2022. (2021,
December 16). American Diabetes Association. Retrieved June 1, 2022, from
https://diabetesjournals.org/care/article/45/Supplement_1/S185/138917/12-Retinopathy-
Neuropathy-and-Foot-Care-Standards?searchresult=1
Syed, S. J., MD. (2021, October 16). Bullous disease of diabetes (bullosis diabeticorum)
guidelines: Guidelines summary. Medscape. Retrieved June 1, 2022, from
https://emedicine.medscape.com/article/1062235-guidelines#g1
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