NURS FPX 4905 Assessment 2 Assessment 02: Define and Analyze Your Healthcare Process Problem or Issue of Concern
Student name
Capella University
NURS- FPX4905
Professor Name
Submission Date
Define and Analyze Your Healthcare Process Problem or Issue of Concern
Chronic diseases, such as type 2 diabetes, remain one of the most pressing health care problems today, and managing those remains a challenge. This problem is especially significant in a community-based outpatient clinic, like the one in Farmington Hills, Mich., that serves a diverse adult population. The assessment provides a discussion of the effects of the lack of care coordination and follow-up on the quality, safety, and cost of care and evidence-based interventions. The role of the nurse, leadership, ethics, and partnerships in the community are mentioned as these improve long-term health outcomes.
Description of Practicum Site
The outpatient community clinic is located at 31300 Northwestern Hwy, Ste A, Farmington Hills, Michigan, which is my practicum site. Diabetes affects around 10.0% (923,400 adults) of all adults in Michigan. The clinic primarily deals with chronic disease management and prevention, including type 2 diabetes, and is interested in the promotion of prevention and wellness. Services include diagnostic testing, managing medications, providing education to the patient, and coordinating care for chronic conditions. This outpatient setting serves as a critical opportunity for the surrounding community, particularly for those adults with multiple health problems.
The majority of the patient population is adult patients, older adults, or the elderly, battling conditions such as serious chronic mental illness, type 2 diabetes, hypertension, and obesity. Barriers to achieving disease control are generally related to a shortage of resources, food insecurity, and irregular access to health care. As described under Disease Prevention and Control, population change, social inequities, and reduced access to health services may be exacerbated by increased pressure on existing health systems, all of which impact the setting of conditions for the establishment of any infectious diseases. This patient population is very heterogeneous with various ethnic, racial, and cultural needs that require patient-centered and culturally competent care. All these factors highlight the significance of the role of the clinic in delivering care—not only for medical needs—but for social determinants of health that affect the outcome.
They estimated 15-20 health care providers were employed in the clinic, and they collaborate to offer comprehensive care to the patient. Staff includes nurse practitioners and registered nurses, medical assistants, behavioral health provider(s), and administrative staff members who ensure clinical and operational processes run smoothly. Evidence from systematic reviews and meta-analyses has shown that models of team-based, inter-professional care may have the potential for improving patient satisfaction and health outcomes. The multidisciplinary unit allows the clinic to provide physical, emotional, and educational requirements, all under one roof. Good teamwork increases cooperation, reduces fragmentation of care, and allows for better patient-centered outcomes to occur.
Clinical and Operational Decisions at the Practicum Site
In the Practicum Site, students make clinical and operational decisions by interacting with patients, other healthcare providers, and the site’s staff. In my practicum, I find that most of the time when clinical decisions are made, there is an initiative of personalized planning of treatment for chronic diseases, management of drug therapy, and educating the patients based on their lifestyle needs. The paper emphasized how vital Case Management can be for enhancing patient flow that ultimately will improve healthcare outcomes, operational efficiency, and cost-effectiveness. Not in a decision-making role yet, play an active role at care planning meetings; promote plans for patient education. As a result of this involvement, I will be more able to assist with communicating with patients and assist with the care team’s recommendations.
Clinically driven outcomes include improved disease control, improved patient self-management, and reduced complications of chronic diseases, such as type 2 diabetes. The complications of diabetes are heart disease, stroke, amputation, end-stage renal disease, blindness, and death. Minimising readmission and attendance to the Emergency Department is a major goal, also in line with quality and safety standards. As part of a long-term success measurement, patient satisfaction and health literacy are also taken into account. The results show the clinic’s commitment to offering affordable, patient-oriented, and green healthcare.
Process Issue Identification
One of the problems that were identified at my practicum setting is the irregular follow-up and care coordination of people with type 2 diabetes. Examples of contributing factors to suboptimal glycemic control and increased complications are missed appointments, the lack of continuity of care provider to provider, and a lack of patient engagement. For example, people with T2DM who did not attend the appointment they had were 24% – 64% more likely to have poor glycemic control and up to 60% more likely to be rehospitalised. The gap directly impacts the clinical outcomes as the clinical burden of untreated blood pressure, obesity, and mental health is already a burden on patients’ struggle with the disease. Clearing all the barriers is crucial for ensuring timely and sustainable care delivery to patients.
It’s a nationwide problem because the adult patients with type 2 diabetes do not meet the target blood glucose level. According to the data from the Centers for Disease Control and Prevention (CDC), more than 34 million people in the USA are suffering from diabetes mellitus (DM), and type 2 DM (T2DM) accounts for 90%–95% of all DM diagnoses (Sun et al., 2021). During 2023, the CDC’s Division of Diabetes Translation awarded a total of $6,472,670 in diabetes prevention and education (DPE) grants in Michigan. Clinically report high rates of non-compliance with the medications and clinic no-shows among financially and/or socially challenged users. Both lead to a rise in both emergency room visits and hospitalizations—both signs of concern for quality and cost. This is important because it is directly associated with patient outcomes, which clearly implores the need for improvements in processes that concern the continuity of care and follow-up.
Impact Analysis
There is a cost to the current inconsistent method of following up type 2 diabetic patients for both the organization and the patients that it serves. With regards to quality, a lack of integrated care limits access to the best quality glycemic targets, leading to an increased risk of other complications such as neuropathy, retinopathy, and cardiovascular disease. Safety is also endangered by a lack of opportunities to intervene early, which can lead to unnecessary hospitalizations and/or adverse blood sugar events. From a financial perspective, any care delayed will cost more to use emergency care, resulting in greater costs for patients and the healthcare system. Various associations had calculated that the cost of medical treatment of diabetes in Michigan is $10 billion. It’s a vicious cycle of the lack of preventive care, resulting in increased long-term costs.
The causes for this process defect are complex. The majority of patients face socioeconomic issues such as food insecurity, lack of dependable transportation, and financial burden, which are all detrimental to their regular clinic visits and adherence to medications. Lost appointments have been shown to primarily correspond to sociodemographic and comorbid conditions, health literacy, distance from the clinic, and other factors, further demonstrating the complexity of barriers faced by patients. Furthermore, there are structural challenges in the clinic that can increase the gap in continuity of care, such as inadequate staffing during outreach or reminders for follow-up. The reason appears to be a lack of coordination of care that directly impacts patient involvement in their care. Without an organization to help patients better complete their track follow-ups, remind them, or consolidate, they will not have a reinforcement to control the chronic diseases. A formal care coordination program is an evidence-based practice at my practicum site. The interventions will be: nurse follow-up calls on a regular basis, calls to set appointments, and virtual visits to continue care. Study confirms that telemedicine is an effective way of enhancing hemoglobin A1c (HbA1c) and consequently glycemic control of type 2 diabetic patients. These findings generate the need for reengineering of the follow-up procedures to enhance outcomes, make progress on safety, and reduce unnecessary costs.
Conclusion
The practicum was an experience of the challenges of caring for Type 2 Diabetes in the diverse adult population. The central issues related to outcomes, safety, and cost were incongruent follow-up and limited care coordination. Evidence-based practices like telehealth visits, culturally responsive teaching, and community engagement offer opportunities for solutions. Last, but not least, there is a pivotal role for nursing leadership, ethics, and community participation to overcome sustainable and patient-centered care.
References
American Diabetes Association. (2024). The Burden of Diabetes in Michigan. https://diabetes.org/sites/default/files/2025-02/adv_2024_state_fact_sheets_2_3_25_final_mi_2.pdf
De-Groot, J., Wu, D., Flynn, D., Robertson, D., Grant, G., & Sun, J. (2021). Efficacy of telemedicine on glycaemic control in patients with type 2 diabetes: A meta-analysis. World Journal of Diabetes, 12(2), 170–197. https://doi.org/10.4239/wjd.v12.i2.170
European Centre for Disease Prevention and Control. (2025, May 8). Future challenges for infectious disease prevention and control. European Centre for Disease Prevention and Control. https://www.ecdc.europa.eu/en/publications-data/future-challenges-infectious-disease-prevention-and-control
Harbi, S. A., Aljohani, B., Elmasry, L., Baldovino, F. L., Raviz, K. B., Altowairqi, L., & Alshlowi, S. (2024). Streamlining patient flow and enhancing operational efficiency through case management implementation. British Medical Journal Open Quality, 13(1), 1–18. https://doi.org/10.1136/bmjoq-2023-002484
Johnson, C., Ingraham, M. K., Stafford, S. R., & Guilamo-Ramos, V. (2024). Adopting a nurse-led model of care to advance whole-person health and health equity within Medicaid. Nursing Outlook, 72(4), 102191. https://doi.org/10.1016/j.outlook.2024.102191
Sun, C.-A., Taylor, K., Levin, S., Renda, S. M., & Han, H.-R. (2021). Factors associated with missed appointments by adults with type 2 diabetes mellitus: A systematic review. British Medical Journal Open Diabetes Research and Care, 9(1), e001819. https://doi.org/10.1136/bmjdrc-2020-001819
FAQs
1. How does the gradual development of a healthcare process problem make it hard to detect in the clinical setting?
A healthcare process problem tends to occur due to inefficiencies in the workflow process that may take time before it negatively affects patients and staff.
2. How does communication lead to process issues for healthcare practitioners?
There may be treatment delays, incorrect documentation, incorrect medication, and inadequate patient handover due to the communication problem among health care professionals.
3. Why is it important for nursing students to study the healthcare process in relation to workflow systems?
The knowledge about the workflow system enables nursing students to understand how clinical practice affects patient safety and productivity.
4. How does technology help solve process problems in healthcare?
Technology helps to facilitate coordination, record keeping, correct patient record tracking, and minimizes human errors in the clinical setting.
5. Why should nursing students propose practical solutions in NURS FPX 4905 Assessment 2?
Proposing practical solutions shows that nursing students can apply their nursing knowledge to address healthcare process problems.