NURS FPX 4005 Assessment 4

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 significantly hindering patient adherence to self-management strategies. The fragmented care coordination and inconsistent communication among healthcare teams prevent real-time collaboration, which leads to suboptimal diabetes management outcomes. This assessment proposes an interdisciplinary care plan to improve communication, enhance patient education, and optimize diabetes care coordination, ultimately improving patient outcomes.

Organizational Issue

SPRHC faces considerable delays in establishing a structured diabetes education program, which negatively impacts patient adherence and overall clinical outcomes. These delays stem from fragmented care coordination, inconsistent communication across interdisciplinary teams, and the lack of standardized workflows. The absence of real-time collaboration between primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists results in misaligned treatment plans. This, in turn, leads to poor glycemic control and increased hospital readmissions.

Beyond the impact on patient health, ineffective interdisciplinary coordination also contributes to staff burnout due to unclear roles and inefficient workflows. Additionally, 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, revealing significant improvements in clinical outcomes, including reductions in systolic blood pressure (−5.88 mmHg), diastolic blood pressure (−3.23 mmHg), and HbA1C (−0.38%). These findings underline 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 collaboration at SPRHC is essential for delivering high-quality, patient-centered care. A formalized diabetes education program would establish standardized protocols, shared decision-making frameworks, and common electronic health record (EHR) templates to enable real-time treatment adjustments. Weekly interdisciplinary rounds will foster enhanced coordination among primary care providers, nurses, dietitians, pharmacists, and behavioral health professionals, optimizing patient outcomes and promoting a teamwork-oriented environment.

Improved communication and reduced inconsistencies in treatment plans would allow healthcare providers to implement evidence-based care more effectively. This would lead to greater job satisfaction and improved patient trust. Additionally, the initiative aligns with SPRHC’s mission to provide comprehensive diabetes management, reinforce patient engagement, and promote long-term adherence to self-care. The program is expected to reduce hospital readmissions, lower healthcare costs, and improve organizational efficiency, ensuring long-term sustainability in diabetes care.

Table: Key Aspects of the Interdisciplinary Diabetes Care Plan

Category	Details
Interdisciplinary Team Approach	Enhances care coordination among primary care providers, endocrinologists, diabetes educators, dietitians, pharmacists, and behavioral health professionals.
Standardized Communication Protocols	SBAR (Situation, Background, Assessment, and Recommendation) will be used for patient handoffs to ensure consistent and effective communication.
Real-Time Data Sharing & Integration	EHR systems will be integrated with a dedicated diabetes management platform for real-time access to patient data, lab results, and medication adherence.
Collaborative Decision-Making & Care Pathways	Development of interdisciplinary care pathways for personalized insulin management, lifestyle interventions, and behavioral support.
Training & Cross-Disciplinary Education	Regular training on diabetes management, motivational interviewing, and shared decision-making will improve collaboration and patient education.

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 utilized 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 expected 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/

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