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Capella 4900 Assessment 2

Assessment 2 – Assessing the Problem; Patient, Family, or Population Health Problem Solution

Student Name

Capella University

FPX4900: Capstone Project for Nursing



Assessing the Problem: Quality, Safety, and Cost Considerations

Globally, healthcare institutions are determined to provide the utmost quality of care to their patients, with a strong emphasis on safety and cost control. Nonetheless, when it comes to handling chronic illnesses such as heart failure and readmission rates associated with them, meeting these objectives can be quite complex. This evaluation aims to delve into the intricate dynamics of managing heart failure and readmission rates, utilizing the specific instance of Taylor, a patient we previously assessed. This case effectively showcases how issues faced by a patient, a family, or a wider population can impact the quality of care, patient safety, and the financial burden on both the healthcare system and the individuals concerned. Additionally, the assessment scrutinizes how the standards of state board nursing practice and various organizational or governmental policies influence these aspects, and puts forward evidence-based strategies for improvements.

Impact of the Problem on Quality of Care, Patient Safety, and Costs

The elevated readmission rates for heart failure patients such as Taylor are a clear indication of compromised quality of care. The issue lies in areas like inadequate discharge planning, insufficient patient education, and suboptimal management of comorbidities. In the case of Taylor, his readmission signifies a failure in the health system to provide him with the necessary tools and education to manage his condition effectively at home. This gap in care delivery significantly reduces the overall effectiveness of the treatment regime, quality of care, and points out a substantial area for improvement (Heidenreich et al., 2022).

Capella 4900 Assessment 2

Each hospital readmission introduces potential hazards to the patient. For instance, the risk of acquiring infections in the hospital setting increases with each admission (Li et al., 2022). Furthermore, the physical and psychological strain associated with repeated hospitalizations can lead to a decline in the overall health status. In Taylor’s situation, his recurrent admissions signify a threat to his safety, as he is continually exposed to these potential risks (Naser et al., 2022).

Capella 4900 Assessment 2

High readmission rates lead to increased healthcare costs, with significant implications for both the healthcare system and the patient. Hospitals face financial penalties by the Medicare services due to high readmission rates, which puts strain on the already limited financial healthcare resources. On the individual level, patients like Taylor and their families face the burden of escalating medical expenses, leading to significant financial distress (Zaki et al., 2020).

Capella 4900 Assessment 2

A study by Combs and colleagues (2022) has shown the correlation between high readmission rates and factors like insufficient patient education and suboptimal management of comorbidities. The financial implications are also backed by research, for instance, Zaki and colleagues (2020) pointed out the reimbursement penalties imposed on healthcare organizations due to high readmission rates.

The supporting evidence aligns with observations in nursing practice. The case of Taylor exemplifies how failures in healthcare delivery, such as insufficient patient education and inadequate follow-up care, lead to recurrent readmissions, negatively impacting the quality of care, patient safety, and healthcare costs. This real-life example underscores the urgent need for improvement in these areas to enhance patient outcomes and alleviate the burden on the healthcare system (Matthews et al., 2023). 

State Board Nursing Practice Standards and Organizational/Governmental Policies

The issues of high readmission rates among heart failure patients like Taylor can be significantly influenced by the standards set by the state board of nursing and various organizational or governmental policies. The effects of these standards and policies are observed in the quality of care, safety of patients, and financial implications for both the healthcare institution and the individual (Shin et al., 2022).

State board nursing practice norms, including the Nursing Practice Acts, delineate the roles and responsibilities of registered nurses, encompassing the assessment, planning, execution, and evaluation of care for heart failure patients (Shin et al., 2022). The defined scope directly affects the quality of care and safety of patients. For example, if the nursing practice norms underscore comprehensive patient education and meticulous discharge planning, it can lead to an improvement in the quality of care and a decrease in readmissions, thereby enhancing patient safety (Fu et al., 2023).

Organizational policies, such as adherence to evidence-based protocols and guidelines for heart failure treatment, can contribute to consistent care and lessen the probability of readmissions. When the guidelines set forth by organizations like the American College of Cardiology and the American Heart Association are integrated into the institution’s policies, better patient outcomes can be expected (Creager et al., 2021). However, if these guidelines are not implemented effectively due to obstacles such as resource constraints or lack of support from leadership, it could negatively impact the quality of care, safety of patients, and financial implications for both the healthcare system and the individual.

Governmental policies or legislation can also influence the problem. For example, policies mandating higher patient-to-nurse ratios might result in nurses having less time to spend on patient education, discharge planning, and follow-up care, which could contribute to increased readmission rates for heart failure patients (Shin et al., 2022). Moreover, such policies can increase the workload and stress of nurses, potentially compromising patient safety and the quality of care. A study by Shin and colleagues (2022) reveals that implementation of a standardized protocol for managing heart failure patients, which includes regular patient follow-ups, intensive patient education, and personalized care plans, significantly reduces the readmission rates. However, these outcomes can greatly vary based on the local implementation and adherence to these protocols. It underscores the importance of proper execution of standards and policies to achieve the desired outcomes.

The nursing practice standards, such as maintaining a safe patient-to-nurse ratio, appropriate delegation of tasks, and adherence to evidence-based treatment guidelines, will be pivotal in tailoring the care for Taylor (Mills & Duddle, 2022). For instance, maintaining an optimal patient-to-nurse ratio ensures that Taylor receives adequate attention and care. Adherence to evidence-based treatment guidelines ensures that Taylor receives the most effective treatment for heart failure, reducing the likelihood of readmission (Goldman & Harte, 2020).

Various policies have a direct bearing on the nursing scope of practice. For example, the Nurse Practice Act in most states defines the roles and responsibilities of nurses, influencing the quality of care they can deliver (Heinen et al., 2019). Governmental policies can also substantially impact the problem. For instance, CMS’s readmission rates policy, the Hospital Readmissions Reduction Program (HRRP), directly affects healthcare institutions by imposing financial penalties for high readmission rates. This policy incentivizes improvements in heart failure management, including nursing practices, to avoid penalties. Similarly, legislations mandating nurse-to-patient ratios influence the workload and stress of nurses, potentially affecting patient safety and the quality of care. Higher ratios might limit the time nurses can spend on patient education, discharge planning, and follow-up care, contributing to increased readmission rates (Shin et al., 2022).

The influence of these policies and standards extends to everyday nursing practices. Nursing practice standards, such as maintaining a safe patient-to-nurse ratio and adherence to evidence-based treatment guidelines, play a significant role in shaping care for patients like Taylor. Policies like the Nurse Practice Act and the Affordable Care Act (ACA) define the roles and responsibilities of nurses, affecting the care they deliver. Also, these policies mandate hospitals to reduce readmission rates, influencing the strategies healthcare institutions employ to manage heart failure patients (Zaki et al., 2020). This, in turn, affects nursing practices as nurses must adapt to these strategies. Thus, understanding and effectively implementing these regulations and legislations is pivotal in planning and delivering effective nursing care.”

Strategies to Improve Quality of Care, Enhance Patient Safety, and Reduce Costs

To improve the quality of care, enhance patient safety, and reduce costs to the system and individual, I propose several strategies. These strategies, rooted in evidence-based practice and tailored to the specific needs and circumstances of heart failure patients like Taylor, aim to not only address the current state of health but also proactively prevent future complications. By integrating a patient-centered approach with a keen understanding of the multidimensional challenges faced by patients with heart failure, these strategies provide a comprehensive path to improved patient outcomes and overall healthcare quality.

  1. Comprehensive Discharge Planning: A complete discharge plan that includes medication reconciliation, patient education, and scheduling follow-up appointments can help reduce the risk of readmission (Shin et al., 2022). This approach ensures that Taylor and his family understand his condition, the importance of medication adherence, and the schedule for follow-up appointments.
  2. Enhanced Patient Education: Enhancing patient education on self-management, medication adherence, and lifestyle modifications is crucial. Proper education can empower Taylor to manage his condition more effectively, leading to improved health outcomes and reduced readmission rates (Cui et al., 2019).
  3. Strengthening Care Coordination: Fostering interdisciplinary collaboration among healthcare professionals can ensure consistent and coordinated care. For instance, frequent communication and collaboration between Taylor’s primary care physician, cardiologist, and home health nurse can lead to better management of his condition (Chau et al., 2020).
  4. Telehealth Monitoring: Telehealth monitoring provides remote support and timely interventions for heart failure patients. In Taylor’s case, telehealth can enable his healthcare team to monitor his condition remotely, intervene promptly if his health deteriorates, and prevent unnecessary hospital readmissions (Chaudhry et al., 2016).
  5. Individualized Patient-Centered Care: Adopting a patient-centered care approach that addresses Taylor’s unique needs and preferences can enhance the quality of care. This approach involves actively involving Taylor in decision-making processes and tailoring care to his individual circumstances and preferences (Hofmeyer & Taylor, 2020).

Throughout this assessment, I spent 2 direct practicum hours with Taylor and his family, exploring the impact of his condition, discussing potential improvement strategies, and consulting with subject matter and industry experts. These hours have been duly documented in the Core Elms Volunteer Experience Form, showcasing my commitment to addressing this problem and improving patient outcomes.


Addressing chronic conditions like heart failure and hospital readmission rates necessitates a comprehensive, patient-oriented, evidence-supported approach. This analysis has stressed the profound influence of a patient’s circumstances on care quality, patient safety, and the financial responsibilities for both the healthcare system and the individual. It highlighted the critical role of nursing practice regulations and policies in mitigating these challenges and offered effective strategies to enhance care, boost safety, and cut costs. Utilizing a real-life case such as Taylor’s has provided valuable insights, making these strategies more relevant and effective. The practicum hours offered further enriched understanding, helping to shape future nursing practice. As healthcare continues to advance, maintaining adaptability, foresight, and resourcefulness is essential.


Creager, M. A., Matsushita, K., Arya, S., Beckman, J. A., Duval, S., Goodney, P. P., … & American Heart Association Advocacy Coordinating Committee. (2021). Reducing nontraumatic lower-extremity amputations by 20% by 2030: Time to get to our feet: A policy statement from the American Heart Association. Circulation, 143(17), e875-e891.

Chau, J. P. C., Lo, S. H. S., Lee, V. W. Y., Yiu, W. M., Chiang, H. C. Y., Thompson, D. R., & Lau, A. Y. L. (2020). Fostering gerontology students’ competence in interprofessional collaborative practice. BMC Medical Education, 20, 1-8.

Combs, C.A., Goffman, D., Pettker, C.M., Society for Maternal-Fetal Medicine (SMFM and Quality Committee. (2022). Society for Maternal-Fetal Medicine special statement: A critique of postpartum readmission rate as a quality metric. American Journal of Obstetrics and Gynecology, 226(4),B2-B9.

Cui, X., Zhou, X., Ma, L. L., Sun, T. W., Bishop, L., Gardiner, F. W., & Wang, L. (2019). A nurse-led structured education program improves self-management skills and reduces hospital readmissions in patients with chronic heart failure: A randomized and controlled trial in China. Rural and remote health, 19(2), 1-8.

Fedson, S., & Bozkurt, B. (2022). Telehealth in heart failure. Heart Failure Clinics, 18(2), 213-221. 

Fu, B. Q., Zhong, C. C., Wong, C. H., Ho, F. F., Nilsen, P., Hung, C. T., … & Chung, V. C. (2023). Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: A systematic review of qualitative studies. International Journal of Health Policy and Management, 12.

Goldman, J. D., & Harte, F. M. (2020). Transition of care to prevent recurrence after acute coronary syndrome: The critical role of the primary care provider and pharmacist. Postgraduate Medicine, 132(5), 426-432.

Heinen, M., van Oostveen, C., Peters, J., Vermeulen, H., & Huis, A. (2019). An integrative review of leadership competencies and attributes in advanced nursing practice. Journal of advanced nursing, 75(11), 2378-2392.

Heidenreich, P.A., Fonarow, G.C., Opsha, Y., Sandhu, A.T., Sweitzer, N.K., Warraich, H.J., Butler, J., Hsich, E., Pressler, S.B., Shah, K. and Taylor, K. (2022). Economic issues in heart failure in the United States. Journal of Cardiac Failure, 28(3), 453-466.

Hofmeyer, A., & Taylor, R. (2021). Strategies and resources for nurse leaders to use to lead with empathy and prudence so they understand and address sources of anxiety among nurses practising in the era of COVID19. Journal of clinical nursing, 30(1-2), 298-305. 

Li, R., Geng, J., Liu, J., Wang, G. and Hesketh, T. (2022). Effectiveness of integrating primary healthcare in aftercare for older patients after discharge from tertiary hospitals: A systematic review and meta-analysis. Age and Ageing, 51(6), afac151.

Malakoane, B., Heunis, J. C., Chikobvu, P., Kigozi, N. G., & Kruger, W. H. (2020). Public health system challenges in the Free State, South Africa: a situation appraisal to inform health system strengthening. BMC Health Services Research, 20(1). 

Matthews, J., Booth, A., Rooney, L., Brennan, C., & McGovern, T. (2023). A pilot study assessing the preliminary efficacy and acceptability of a mental health promotion e-learning module for sports coaches. Children’s Health Care, 1-23.

Mills, S. L., & Duddle, M. (2022). Missed nursing care in Australia: Exploring the contributing factors. Collegian, 29(1), 125-135.

Naser, A.Y., Alwafi, H., Hemmo, S.I., Alrawashdeh, H.M., Alqahtani, J.S., Alghamdi, S.M. and Mustafa Ali, M.K.  (2022). Trends in hospital admissions due to neoplasms in england and wales between 1999 and 2019: An ecological study. International Journal of Environmental Research and Public Health, 19(13), 8054.

Shin, D. Y., Chang, J., Ramamonjiarivelo, Z. H., & Medina, M. (2022). Does Geographic Location Affect the Quality of Care? The Difference in Readmission Rates Between the Border and Non-Border Hospitals in Texas. Risk Management and Healthcare Policy, 1011-1023.

Zaki, N., Alashwal, H., & Ibrahim, S. (2020). Association of hypertension, diabetes, stroke, cancer, kidney disease, and high-cholesterol with COVID-19 disease severity and fatality: A systematic review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14(5), 1133–1142.

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