D159 CPE Record: Leadership and Management E-Portfolio Template

D159 CPE Record: Leadership and Management E-Portfolio Template

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Name

 Western Governors University

D158 Strategically Planning the Execution of a Healthcare Improvement Project

Prof. Name

Date

Leadership and Management E-Portfolio Template

Phase 1 Task Overview

Phase 1 of the Leadership and Management E-Portfolio centers on foundational activities such as planning, documenting, and conceptualizing the initial project framework. The completion of these tasks is critical as it sets the stage for the successful implementation and subsequent evaluation of the project. This phase ensures that all necessary groundwork is laid for efficient project execution.

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Phase 1 Task Completion Overview

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

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Project Report Plan

What Is the Project Aim?

The core objective of this project is to establish and execute a structured telehealth follow-up protocol wherein nurse case managers contact psychiatric patients within seven days after discharge from an acute behavioral health hospitalization. This initiative aims to improve continuity of care by fostering patient engagement in outpatient psychiatric services. Additionally, it seeks to lower the rate of psychiatric rehospitalization within 30 days of discharge. Research shows that early post-discharge contact can promote adherence to treatment plans and reduce relapse risks during this vulnerable transition period (Smith & Jones, 2022).

Who Is the Project Manager?

Amanda Howell has been designated as the Project Manager. She plays a pivotal leadership role, managing project coordination, timeline adherence, data collection and analysis, and facilitating effective communication among stakeholders. Furthermore, she oversees performance tracking and guides efforts aimed at continuous quality improvement.

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Essential Data for Analysis

What Data Are Essential for Evaluating Project Outcomes?

To assess the success of the telehealth follow-up intervention, several critical data elements will be gathered and analyzed. These include:

• Demographic information of psychiatric patients discharged from the behavioral health unit.
• The rate of rehospitalization within 30 days post-discharge.
• The percentage of patients attending outpatient psychiatric follow-up appointments within seven days after discharge.

These indicators collectively measure patient outcomes and the efficiency of healthcare delivery systems (Agency for Healthcare Research and Quality [AHRQ], 2023).

How Will Patient Data Be Protected?

Patient confidentiality and data security are paramount. Access to patient data will be restricted to a secure organizational database compliant with healthcare privacy regulations such as HIPAA. The project manager controls access permissions, ensuring only authorized team members handle sensitive information. Data for analysis will be extracted and stored in encrypted Excel files on secure networks, minimizing risks of unauthorized access (World Health Organization [WHO], 2021).

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Data Presentation and Reporting

How Will Project Results Be Presented?

Results will be displayed using both graphical and tabular formats to enhance stakeholder understanding. Comparative charts will demonstrate variations in 30-day rehospitalization rates and 7-day follow-up compliance before and after the telehealth intervention implementation. Accompanying tables will provide precise numerical data, enabling leadership to monitor trends, measure progress, and identify areas that require further improvement.

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Project Team Roles and Responsibilities

Who Are the Project Team Members and What Are Their Roles?

The project team is headed by the project manager, who oversees the entire process, including evaluation. Weekly data reviews will be conducted to track rehospitalization rates and compliance with follow-up appointments. These sessions support early identification of challenges, promote accountability, and guide necessary adjustments to the intervention plan.

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Targeted Performance Metrics

What Metrics Will Be Used to Measure Success?

Performance metrics have been identified that align with organizational quality improvement goals. These include:

Metric	Target Outcome
Staff Training	100% of relevant staff trained before launch
Audit Frequency	Weekly audits conducted by the project manager
Psychiatric Rehospitalization	Significant reduction in 30-day rehospitalization rates
Follow-Up Appointment Compliance	Increase in patients attending 7-day follow-up visits

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GoReact Video Summary (Phase 1)

The Phase 1 GoReact video emphasized the creation of a telehealth follow-up system for psychiatric patients transitioning from inpatient care. The project manager’s leadership was highlighted, focusing on data oversight, staff engagement, and outcome evaluation. Key data points included patient demographics, rehospitalization rates, and follow-up attendance. Secure data management and routine weekly audits were identified as essential for project success.

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Phase 2 Task Overview

Building on Phase 1, Phase 2 focuses on detailed data management, continuous performance tracking, and rigorous outcome evaluation to ensure the project’s goals are met and sustained.

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Phase 2 Task Completion Overview

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

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Data Management Plan

What Are the Three Primary Data Elements to Track?

The focus is on tracking three primary data points:

1. Number of project team members trained in the telehealth follow-up process.
2. Rates of psychiatric rehospitalization within 30 days.
3. Patient compliance with outpatient follow-up appointments within seven days of discharge.

These data elements provide a comprehensive view of team readiness, implementation effectiveness, and patient outcomes.

What Data Sources Will Be Used to Evaluate Project Success?

The electronic medical record (EMR) system will be the primary source of data. Relevant information will be securely extracted from the EMR and transferred to a password-protected Excel spreadsheet. Access will be limited to authorized project personnel to maintain data integrity and confidentiality (Kruse et al., 2017).

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Key Performance Indicators and Benchmarks

KPI	Description
Staff Training Completion	All designated staff must complete telehealth process education prior to project launch.
Weekly Audits	Continuous monitoring of rehospitalization and follow-up rates.

The project benchmarks align with SMART goals by targeting a 5% increase in outpatient follow-up attendance within seven days and a 2% reduction in 30-day psychiatric rehospitalization. These goals are specific, measurable, achievable, relevant, and time-bound to ensure effective performance evaluation (Substance Abuse and Mental Health Services Administration [SAMHSA], 2020).

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Quantitative Data Collection and Analysis

How Will Quantitative Data Be Collected?

Data will be systematically extracted from the EMR by the project manager, focusing on patients discharged from the psychiatric unit. Key data points include readmission status within 30 days and follow-up appointment attendance within seven days.

What Parameters Will Be Used for Data Collection?

Parameters include admission and discharge dates, patient age, psychiatric diagnosis, scheduled outpatient appointments, and insurance or payor source. These details facilitate stratified analysis and help identify trends affecting patient outcomes.

How Will High-Priority Data Be Analyzed and Interpreted?

Data analysis will emphasize accuracy, completeness, and relevance. The interpretation will consider contextual factors, biases, and data limitations, ensuring objective evaluation of the telehealth intervention’s effectiveness and guiding future improvements.

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Potential Challenges and Limitations

What Issues Could Impact Project Results?

Several challenges may affect data quality and interpretation. Insurance claim processing delays can impact rehospitalization reporting accuracy. Additionally, follow-up appointments completed outside the organization’s network might not be recorded in the EMR. These factors will be transparently acknowledged to maintain responsible reporting standards.

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GoReact Video Summary (Phase 2)

The Phase 2 GoReact video underscored the importance of structured data management and consistent performance monitoring. Key highlights included staff education tracking, rehospitalization rates, follow-up compliance, SMART goal benchmarks, secure data handling, and awareness of data gaps that could affect the project’s validity and sustainability.

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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