NURS FPX 4005 Assessment 4

Name

Capella university

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

Prof. Name

Date

Stakeholder Presentation

Hi, _ here. I will guide you through addressing delays in implementing an integrated diabetes education program at St. Paul Regional Health Center (SPRHC). Fragmented care coordination and inconsistent communication hinder real-time collaboration, affecting patient adherence to self-management. This assessment presents an interdisciplinary care plan to improve communication, patient education, and diabetes management.

Organizational Issue

A significant concern at SPRHC is the delay in implementing an integrated diabetes education program, which impacts patient adherence to self-management strategies. These delays are primarily caused by fragmented care coordination and inconsistent communication among interdisciplinary teams. Additionally, the lack of a structured workflow for patient education contributes to these delays. The absence of real-time collaboration between primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists often leads to misaligned treatment plans, creating gaps in diabetes management.

Such inefficiencies can result in poor glycemic control, increased hospital readmissions, and higher long-term healthcare costs. Besides its impact on patient outcomes, inadequate interdisciplinary coordination also reduces staff morale. Healthcare professionals often struggle with unclear roles and ineffective workflows, which can lead to burnout. Moreover, SPRHC’s reputation could suffer if ineffective diabetes management deters future patients and limits the hospital’s ability to attract top healthcare talent.

Tandan et al. (2024) conducted a systematic review and meta-analysis of 54 studies (1988–2021) to assess the impact of team-based interventions on chronic disease outcomes in primary care. The findings demonstrated significant reductions in systolic blood pressure (−5.88 mmHg), diastolic blood pressure (−3.23 mmHg), and HbA1C (−0.38%), with better outcomes when 4–5 teamwork components were involved. However, individual components alone had no significant effect on HbA1C, emphasizing the importance of a structured, interdisciplinary approach. These findings support the need for a structured diabetes education program at SPRHC to enhance multidisciplinary collaboration, improve patient outcomes, and reduce hospital costs.

Importance of the Issue

Addressing gaps in diabetes education and interdisciplinary practice at SPRHC is essential to providing high-quality, patient-focused care. A formalized diabetes education program will enhance workflow effectiveness by setting up standardized protocols, shared decision-making, and common EHR templates. These changes will allow for real-time treatment adjustments through weekly interdisciplinary rounds. Improving coordination between primary care providers, nurses, dietitians, pharmacists, and behavioral health professionals will maximize clinical outcomes while promoting a teamwork environment.

Efficient communication and minimized treatment variability will enable providers to deliver effective, evidence-based care while enhancing job satisfaction. This project supports SPRHC’s mission of providing comprehensive diabetes care, building patient trust, and encouraging long-term patient participation. Ultimately, it will reduce hospital readmissions, decrease healthcare expenses, and enhance organizational effectiveness, ensuring sustainable excellence in diabetes care.

Importance of an Interdisciplinary Team Approach

At SPRHC, improved care coordination among primary care providers, endocrinologists, diabetes educators, dietitians, pharmacists, and behavioral health professionals is critical to optimizing Type 2 diabetes care. A formal multidisciplinary approach will include the following strategies:

Standardized Communication Protocols: Using the SBAR (Situation, Background, Assessment, and Recommendation) protocol for patient handoffs will improve team communication, ensuring that care plans are consistently followed and adjusted according to patient progress.
Real-Time Data Sharing and Integration: Integrating EHR systems with a dedicated diabetes management platform will allow healthcare providers to access real-time patient data, lab results, and medication adherence. This will enable immediate adjustments to treatment plans, improving glycemic control.
Collaborative Decision-Making and Care Pathways: Developing interdisciplinary care pathways, including personalized insulin management, lifestyle interventions, and behavioral support, will ensure a seamless transition from diagnosis to long-term diabetes management. This approach will reduce complications such as neuropathy, nephropathy, and cardiovascular disease.
Training and Cross-Disciplinary Education: Ongoing training on diabetes management, motivational interviewing techniques, and shared decision-making strategies will enhance collaboration among team members. Joint rounds and interdisciplinary workshops will strengthen communication, improve patient education, and support adherence to self-care behaviors.

Interdisciplinary Team Roles

Nurse Leaders: Facilitate clear handoffs using the SBAR protocol, ensure patient education on diabetes self-management, and promote collaboration between disciplines to enhance care coordination.
Diabetes Educators: Provide structured education on blood glucose monitoring, medication adherence, and lifestyle modifications, empowering patients to manage their condition effectively.
Pharmacists: Optimize medication regimens, counsel patients on insulin use and oral hypoglycemics, and ensure adherence to prescribed treatments through medication therapy management.
Behavioral Health Specialists: Address psychological barriers such as stress, depression, and emotional eating, helping patients adopt and sustain self-care behaviors.

Attaining Better Results

Strengthening interdisciplinary care at SPRHC will improve patient outcomes and maximize care effectiveness. Adhering to formalized communication approaches such as SBAR will reduce care transition errors and enhance self-management training. Nurchis et al. (2022) found that interprofessional working (IPC) for managing type 2 diabetes improved patient satisfaction (SMD 0.32) and psychological well-being (SMD 0.18), with potentially positive effects on self-care and quality of life. EHR integration facilitates real-time information sharing, enabling healthcare professionals to make timely, evidence-based decisions on medication adjustments, lifestyle modifications, and behavioral health care (Tamunobarafiri et al., 2024).

Ongoing interdisciplinary meetings will foster teamwork, respect, and shared responsibility, creating a culture of collective accountability. Furthermore, continued training in diabetes care and patient-centered communication will optimize staff productivity and patient compliance. Since communication failure contributes to poor glycemic control, high hospitalization rates, and increased care costs, a well-organized interdisciplinary care process will lead to improved patient outcomes, fewer complications, and more efficient long-term resource management at St. Paul.

Consequences of Inaction

Failure to implement an interdisciplinary diabetes management program at SPRHC could have serious consequences. Without organized communication and care coordination, patients may experience delayed diagnoses, suboptimal glycemic control, and avoidable complications, such as diabetic ketoacidosis, neuropathy, and cardiovascular disease. Additionally, failure to use real-time data sharing through EHR systems may result in medication errors, inconsistent follow-ups, and missed opportunities for early intervention.

Staff burnout and turnover could increase due to inadequate communication and broken workflows, leading to diminished job satisfaction and compromised care quality. Inefficient care coordination may also result in higher hospital readmission rates and more frequent emergency department visits, driving up operational expenses and straining hospital resources. Without a formal interdisciplinary process, SPRHC could face decreased patient satisfaction, worse health outcomes, and an inability to meet its institutional diabetes care goals.

Summary of the Interdisciplinary Plan

An evidence-based interprofessional plan has been developed to address gaps in diabetes care coordination at SPRHC. The plan aims to improve communication, patient education, and multidisciplinary collaboration to enhance diabetes self-management and reduce hospital readmissions. Key stakeholders include primary care clinicians, nurses, dietitians, pharmacists, behavioral health professionals, and healthcare IT specialists. Core strategies involve using SBAR for formal handoffs, EHR integration for real-time data sharing, and frequent interdisciplinary meetings to review patient progress and adjust care plans (Colvin et al., 2023).

Training programs will focus on overcoming communication barriers, such as cultural competency, health literacy, and motivational interviewing, to ensure effective patient education and adherence to treatment plans. The goal is to improve glycemic control, increase patient self-management, and decrease hospital readmissions and complications. Nurchis et al. (2022) found that interdisciplinary diabetes care greatly improved patient outcomes and reduced healthcare costs.

Additionally, structured communication tools like SBAR have enhanced team coordination, reduced medical errors, and improved staff satisfaction. By implementing these strategies, SPRHC can manage diabetes more effectively, improve patient outcomes, lower operational costs, and enhance staff morale through the pursuit of high-quality, patient-focused care (Colvin et al., 2023).

Implementation and Resource Management

Effective planning and resource allocation are critical for implementing the interdisciplinary diabetes education program at SPRHC. The Plan-Do-Study-Act (PDSA) cycle will support the sustainability and improvement of diabetes self-management and patient outcomes.

Planning Phase: During the planning phase, SPRHC will identify key challenges such as low patient compliance, inadequate diabetes education, and fragmented care coordination. An extensive training program will be created for primary care physicians, nurses, dietitians, pharmacists, and behavioral health professionals to improve communication, patient education, and documentation. Structured diabetes education sessions, medication counseling, and real-time sharing of glucose monitoring results will be standardized. Feedback systems, such as patient surveys and staff input, will be used to assess the program’s effectiveness before implementation.
Doing Phase: During the doing phase, a small group of patients will participate in the new diabetes education program. Staff will engage in simulations and pilot workshops to refine interdisciplinary teamwork and patient engagement strategies. EHR integration will be tested to ensure real-time data sharing and coordinated interventions. Patient adherence to medication, diet, and exercise plans will be monitored.
Study Phase: Data from the pilot program will be analyzed, focusing on key performance indicators (KPIs) such as improved glycemic control (A1C levels), medication adherence rates, and reduced hospital readmissions. Staff and patient feedback will be collected to refine education materials, communication strategies, and care coordination efforts.
Act Phase: Based on the results of the pilot phase, the program will be expanded hospital-wide, improving diabetes education and integrating ongoing support. Refresher training, quarterly interdisciplinary meetings, and regular audits will ensure continued progress. Continuous data monitoring and patient feedback will drive long-term success and optimization of the multidisciplinary diabetes management program.

Management of Resources

Effective management of both human and financial resources is essential to SPRHC’s diabetes care coordination strategy. While initial investments in staff training, technology upgrades, and patient education materials will be high, the long-term benefits of improved patient outcomes and decreased hospitalization will offset these costs. According to the American Diabetes Association (2024), well-coordinated care improves patient compliance and reduces healthcare utilization and complications (ADA, 2024). Strategic staffing will ensure smooth collaboration among physicians, nurses, educators, and pharmacists. Additionally, healthcare IT staff will facilitate EHR integration for real-time information sharing (Tamunobarafiri et al., 2024).

The projected annual cost for training programs, EHR upgrades, and patient education materials is estimated between $250,000 and $450,000. However, this investment is expected to result in significant long-term benefits, including reduced hospitalization rates due to better glucose control, fewer medication errors through pharmacist involvement, and lower long-term costs associated with diabetes-related complications. Furthermore, improved patient adherence and higher satisfaction scores will contribute to overall healthcare quality and institutional efficiency. By prioritizing structured diabetes care coordination, SPRHC can enhance patient safety, optimize resource utilization, and improve long-term health outcomes for individuals with diabetes.

Role of Technology

Technology plays a crucial role in enhancing diabetes care coordination at SPRHC. The integration of EHR systems with real-time data-sharing tools enables smooth communication among providers, minimizing errors and improving patient safety. Lab results, glucose levels, and treatment information are immediately available to healthcare teams. Patient-centered tools, such as continuous glucose monitoring (CGM) systems and MyChart, facilitate self-management and enable timely interventions. Telehealth services further expand access, offering virtual consultations, medication titration, and lifestyle coaching for remote patients (Dhediya et al., 2022).

Evaluation of Outcomes

To assess the effectiveness of SPRHC’s interdisciplinary diabetes management approach, key performance indicators (KPIs) will track communication efficiency, staff adherence, patient safety, and satisfaction. Baseline data on communication challenges, such as delayed glucose level updates or incomplete patient history transfers, will be collected before implementation. After the introduction of enhanced coordination protocols, these issues will be monitored quarterly, with a goal to reduce communication failures by 30% within six months. Improved collaboration among endocrinologists, primary care providers, and diabetes educators will reduce errors. Regular audits and staff observations will measure compliance with new protocols, including standardized handoffs and real-time EHR updates (Tamunobarafiri et al., 2024). Staff satisfaction surveys will gauge workflow efficiency and highlight areas for improvement. Patient outcomes will be tracked through adverse event rates, diabetes-related hospital readmissions, and satisfaction scores, ensuring better care coordination. Quarterly performance reviews will incorporate feedback from both staff and patients to refine strategies and maintain long-term effectiveness.

Conclusion

An interdisciplinary diabetes program at SPRHC will improve care coordination, increase communication, and reduce errors through EHR utilization. Enhanced training will optimize staff productivity, and technology will empower patient self-management. Ongoing evaluations will ensure continuous progress. This structured approach will improve patient outcomes and decrease hospital readmissions, ultimately advancing high-quality, patient-centered care at SPRHC.

References

ADA. (2024). About Diabetes |American Diabetes Association. 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. 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/

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