NURS FPX 4005 Assessment 4

Student Name

Capella University

NURS-FPX4005 Nursing Leadership: Focusing on People, Processes, and Organizations

Prof. Name

Date

Stakeholder Presentation

Delays in implementing an integrated diabetes education program at St. Paul Regional Health Center (SPRHC) are negatively impacting patient adherence to self-management strategies. Fragmented care coordination and inconsistent communication among healthcare teams hinder real-time collaboration, leading to suboptimal diabetes management outcomes. This assessment proposes an interdisciplinary care plan aimed at improving communication, enhancing patient education, and optimizing diabetes care coordination to improve patient outcomes.

Organizational Issue

SPRHC is experiencing significant delays in launching a structured diabetes education program, which is adversely affecting patient adherence and overall clinical outcomes. These delays primarily arise from fragmented care coordination, inconsistent communication among interdisciplinary teams, and a lack of standardized workflows. The absence of real-time collaboration among primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists results in misaligned treatment plans, leading to poor glycemic control and increased hospital readmissions.

In addition to compromising patient health, ineffective interdisciplinary coordination contributes to staff burnout due to unclear roles and inefficient workflows. Furthermore, the hospital’s reputation is at risk, as inadequate diabetes management may deter potential patients and hinder the recruitment of top healthcare professionals.

A systematic review by Tandan et al. (2024) examined 54 studies on team-based interventions for chronic disease management in primary care. The findings highlighted significant improvements, such as reductions in systolic blood pressure (−5.88 mmHg), diastolic blood pressure (−3.23 mmHg), and HbA1C (−0.38%), particularly when multiple teamwork components were integrated. These results emphasize the need for a structured, interdisciplinary approach in diabetes education at SPRHC to enhance collaboration, improve patient outcomes, and reduce healthcare costs.

Importance of the Issue

Addressing deficiencies in diabetes education and interdisciplinary practice at SPRHC is critical for delivering high-quality, patient-centered care. A formalized diabetes education program will establish standardized protocols, shared decision-making frameworks, and common electronic health record (EHR) templates to facilitate real-time treatment adjustments. Weekly interdisciplinary rounds will enhance coordination among primary care providers, nurses, dietitians, pharmacists, and behavioral health professionals, optimizing patient outcomes while fostering a teamwork-oriented environment.

By improving communication and reducing inconsistencies in treatment plans, healthcare providers can implement evidence-based care more effectively, leading to higher job satisfaction and improved patient trust. This initiative aligns with SPRHC’s mission to provide comprehensive diabetes management, reinforce patient engagement, and promote long-term adherence to self-care. Additionally, the initiative is expected to decrease hospital readmissions, reduce healthcare costs, and enhance organizational efficiency, ensuring long-term sustainability in diabetes care.

Table: Key Aspects of the Interdisciplinary Diabetes Care Plan

Implementation and Resource Management

The successful implementation of an interdisciplinary diabetes education program at SPRHC requires a structured approach with proper resource allocation. The Plan-Do-Study-Act (PDSA) cycle will be employed to ensure sustainability and continuous improvement:

• Planning Phase: Identify major challenges such as low patient compliance, inadequate diabetes education, and inefficient care coordination. Training programs will be developed for primary care teams, nurses, dietitians, pharmacists, and behavioral health professionals to enhance communication and patient education.
• Doing Phase: A pilot group of patients will be enrolled in the diabetes education program. Staff will undergo simulation exercises and workshops to refine teamwork and engagement strategies.
• Study Phase: Performance indicators such as improved glycemic control (A1C levels), medication adherence, and reduced hospital readmissions will be analyzed. Staff and patient feedback will guide refinements.
• Act Phase: The program will be expanded hospital-wide, supported by ongoing training, quarterly interdisciplinary meetings, and continuous monitoring of patient outcomes.

Strategic financial planning is critical to sustaining the program. Initial costs for training, technology, and patient education are estimated between $250,000 and $450,000 annually. However, this investment is projected to reduce long-term healthcare expenses by improving glucose control, lowering hospitalization rates, and decreasing diabetes-related complications (American Diabetes Association [ADA], 2024). Effective resource allocation, including optimized staffing and EHR integration, will further enhance care coordination (Tamunobarafiri et al., 2024).

References

American Diabetes Association (ADA). (2024). About diabetes. Diabetes.org. https://diabetes.org/about-diabetes

Colvin, C. L., Akinyelure, O. P., Rajan, M., Safford, M. M., Carson, A. P., Muntner, P., Colantonio, L. D., & Kern, L. M. (2023). Diabetes, gaps in care coordination, and preventable adverse events. The American Journal of Managed Care, 29(6), e162–e168. https://doi.org/10.37765/ajmc.2023.89374

Dhediya, R., Chadha, M., Bhattacharya, A. D., Godbole, S., & Godbole, S. (2022). Role of telemedicine in diabetes management. Journal of Diabetes Science and Technology, 17(3), 193229682210811. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10210114/

NURS FPX 4005 Assessment 4

Nurchis, M. C., Sessa, G., Pascucci, D., Sassano, M., Lombi, L., & Damiani, G. (2022). Interprofessional collaboration and diabetes management in primary care: A systematic review and meta-analysis of patient-reported outcomes. Journal of Personalized Medicine, 12(4). https://doi.org/10.3390/jpm12040643

Tamunobarafiri, G., Aderonke, J., Cosmos, C., None Mojeed Dayo Ajegbile, & None Samira Abdul. (2024). Integrating electronic health records systems across borders: Technical challenges and policy solutions. International Medical Science Research Journal, 4(7), 788–796. https://doi.org/10.51594/imsrj.v4i7.1357

Tandan, M., Dunlea, S., Cullen, W., & Bury, G. (2024). Teamwork and its impact on chronic disease clinical outcomes in primary care: A systematic review and meta-analysis. Public Health, 229, 88–115. https://doi.org/10.1016/j.puhe.2024.01.019