D159 CPE Record: Leadership and Management E-Portfolio Template
Student Name
Western Governors University
D159 Evidence-Based Measures for Evaluating Healthcare Improvements
Prof. Name
Date
Leadership and Management E-Portfolio Template
Phase 1 Task Overview
Phase 1 centers on the initial stages of the leadership and management e-portfolio project. This phase involves comprehensive planning, documentation, and the preliminary conceptualization of the project. Completing these tasks lays a solid foundation that ensures efficient project execution and thorough evaluation.
Table 1
Summary of Phase 1 Task Completion
| Task | Estimated Time to Complete | Date Completed |
|---|---|---|
| CPE Table | 1 hour | 2/11/2025 |
| Project Report Template | 4 hours | 2/12/2025 |
| GoReact Videos | 2 hours | 2/14/2025 |
| GoReact Video Summary | 1 hour | 2/14/2025 |
Project Report Plan
What is the Project Aim?
The main goal of this initiative is to establish and implement a structured telehealth follow-up protocol. Nurse case managers will contact psychiatric patients within seven days after discharge from acute behavioral health hospitalization. This strategy aims to enhance continuity of care and patient engagement with outpatient psychiatric services. Moreover, it seeks to reduce psychiatric rehospitalizations within 30 days. Early follow-up after discharge is critical for supporting treatment adherence and decreasing relapse during this vulnerable transition phase.
Who is the Project Manager?
Amanda Howell has been appointed as the Project Manager. In this leadership capacity, she is accountable for coordinating all project activities, ensuring deadlines are met, overseeing data collection and analysis, and facilitating communication among stakeholders. Additionally, she monitors project performance indicators and leads continuous quality improvement efforts.
Essential Data for Analysis
What Data Are Essential for Evaluating Project Outcomes?
Key data elements essential for evaluating this telehealth intervention include demographic information of discharged psychiatric patients, 30-day rehospitalization rates, and rates of outpatient psychiatric follow-up appointments completed within seven days of discharge. These metrics collectively provide insight into patient outcomes and the efficiency of system-level processes.
How Will Patient Data Be Protected?
To ensure confidentiality, patient information will only be accessed through a secure organizational database compliant with healthcare privacy laws such as HIPAA. The project manager will control access permissions tightly, restricting data handling to authorized personnel. All extracted data will be encrypted and stored on a secure network, minimizing risks of unauthorized disclosure while maintaining compliance with institutional and regulatory requirements.
Data Presentation and Reporting
How Will Project Results Be Presented?
Project outcomes will be presented using both graphical and tabular formats to enhance clarity and facilitate stakeholder understanding. Comparative charts will display changes in rehospitalization rates and follow-up appointment compliance before and after the telehealth program implementation. Detailed tables will provide precise numerical data, enabling leadership to quickly recognize trends and identify areas that require attention.
Project Team Roles and Responsibilities
Who Are the Project Team Members and What Are Their Roles?
The project team is led by the project manager, Amanda Howell, who oversees project execution and evaluation. The team conducts weekly reviews of 30-day rehospitalization rates and outpatient follow-up appointment compliance to detect barriers promptly, maintain accountability, and inform necessary adjustments to the intervention.
Targeted Performance Metrics
What Metrics Will Be Used to Measure Success?
Several key performance indicators have been established to assess both the fidelity of implementation and the achievement of desired outcomes. These metrics are aligned with organizational quality improvement goals.
Table 2
Targeted Project Metrics
| Metric | Target Outcome |
|---|---|
| Staff Training | 100% of relevant staff trained before project launch |
| Audit Frequency | Weekly audits conducted by the project manager |
| Psychiatric Rehospitalization | Reduction in 30-day rehospitalization rates |
| Follow-Up Appointment Compliance | Increased attendance of 7-day outpatient appointments |
GoReact Video Summary (Phase 1)
The Phase 1 GoReact video highlighted the creation of a telehealth follow-up system for psychiatric patients transitioning from inpatient care. The project manager’s central role in data oversight, staff engagement, and outcome evaluation was emphasized. The importance of secure data management and routine audits for ongoing project success was also underscored.
Phase 2 Task Overview
Building on Phase 1, Phase 2 emphasizes structured data management, performance monitoring, and outcome evaluation, ensuring the project’s ongoing success.
Table 3
Summary of Phase 2 Task Completion
| Task | Estimated Time to Complete | Date Completed |
|---|---|---|
| CPE Table | 1 hour | 2/11/2025 |
| Data Management Plan Template | 4 hours | 2/13/2025 |
| GoReact Videos | 2 hours | 2/14/2025 |
| GoReact Video Summary | 1 hour | 2/14/2025 |
Data Management Plan
What Are the Three Primary Data Elements to Track?
The project tracks three critical data points: the number of team members trained on the telehealth follow-up process, 30-day psychiatric rehospitalization rates, and patient adherence to outpatient follow-up appointments within seven days post-discharge. These indicators measure staff readiness, implementation success, and patient outcomes.
What Data Sources Will Be Used to Evaluate Project Success?
The electronic medical record (EMR) system serves as the primary data source. Extracted data will be transferred into a secure Excel file accessible only to authorized team members, ensuring data confidentiality and integrity.
Key Performance Indicators and Benchmarks
What Are the Key Performance Indicators for This Process?
Table 4
Key Performance Indicators
| KPI | Description |
|---|---|
| Staff Training Completion | All designated staff complete education before project launch |
| Weekly Audits | Regular monitoring of rehospitalization and follow-up rates |
What Benchmarks Align With the SMART Goal?
The project’s benchmarks adhere to SMART criteria by aiming for a 5% increase in 7-day outpatient follow-up attendance and a 2% reduction in psychiatric rehospitalization rates. These goals are specific, measurable, achievable, relevant, and time-bound, which supports meaningful evaluation of project progress.
Quantitative Data Collection and Analysis
How Will Quantitative Data Be Collected?
The project manager will systematically extract quantitative data from the EMR, focusing on psychiatric patients discharged from the unit, their readmission status within 30 days, and completion of follow-up visits within seven days.
What Parameters Will Be Used for Data Collection?
Data parameters include admission and discharge dates, patient age, psychiatric diagnoses, outpatient appointment schedules, and insurance or payor sources. This detailed data enables stratified analysis to detect trends affecting outcomes.
How Will High-Priority Data Be Analyzed and Interpreted?
Data analysis will emphasize accuracy and relevance, considering contextual factors, potential biases, and data limitations. Objective evaluation will determine the telehealth intervention’s effectiveness and inform ongoing quality improvement.
Potential Challenges and Limitations
What Issues Could Impact Project Results?
Challenges that may affect data accuracy include delays in insurance claims impacting rehospitalization reporting and follow-up visits occurring outside the organization’s network, which may not be reflected in the EMR. These factors will be transparently acknowledged during analysis to ensure responsible reporting.
GoReact Video Summary (Phase 2)
The Phase 2 video summary reinforced the significance of systematic data management and consistent performance monitoring. Emphasis was placed on tracking staff training, rehospitalization rates, and follow-up compliance, alongside secure data handling and acknowledgment of potential data gaps to sustain project validity.
References
Agency for Healthcare Research and Quality. (2023). Best practices in telehealth follow-up care. https://www.ahrq.gov/telehealth
Kruse, C. S., Krowski, N., Rodriguez, B., Tran, L., Vela, J., & Brooks, M. (2017). Telehealth and patient satisfaction: A systematic review and narrative analysis. BMJ Open, 7(8), e016242. https://doi.org/10.1136/bmjopen-2017-016242
Smith, J., & Jones, L. (2022). Reducing psychiatric rehospitalizations: Evidence-based interventions. Journal of Psychiatric Nursing, 36(4), 213–220. https://doi.org/10.1016/j.apnu.2021.12.005
D159 CPE Record: Leadership and Management E-Portfolio Template
Substance Abuse and Mental Health Services Administration. (2020). Continuity of care in behavioral health services. https://www.samhsa.gov
World Health Organization. (2021). Data protection and privacy in healthcare. https://www.who.int/data-protection-healthcare
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