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

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 project aims to develop a telehealth follow-up process where nurse case managers conduct calls to psychiatric patients within the first seven days after discharge from acute hospitalization. The main goal is to reduce psychiatric rehospitalization rates and improve adherence to outpatient psychiatric treatment.

Who is the Project Manager?
Amanda Howell is designated as the Project Manager responsible for overseeing the project activities.

Essential Data for Analysis

The critical data points for evaluation include:

Demographic details of psychiatric patients discharged from the behavioral health unit.
Rehospitalization rates within 30 days post-discharge.
Rates of patient follow-up appointments completed within 7 days after discharge.

How will patient data be protected?

Patient information will be retrieved from a secure database. The project manager controls access, ensuring only authorized team members can access this sensitive data. Data sharing will occur exclusively through a secured Excel file, accessible only to project team members, safeguarding patient confidentiality and compliance with privacy regulations.

How will results be presented?

Results will be demonstrated using graphical and tabular formats that compare rehospitalization and 7-day follow-up rates before and after the project implementation. This visual representation will highlight the impact of the telehealth intervention on patient outcomes.

Who are the project team members, and what are their roles?

The project manager will be responsible for weekly review of the data reports, focusing on the 30-day rehospitalization and 7-day follow-up compliance rates to track the progress and effectiveness of the intervention.

What are the targeted metrics?

Metric	Target
Staff Training	100% of staff trained before the project launch
Audit Frequency	Weekly audits conducted by the project manager
Psychiatric Rehospitalization	Decrease in rehospitalization rates
Psychiatric Follow-Up Appointment Compliance	Increase in follow-up appointment attendance rates

GoReact Video Summary (Phase 1)

The project focuses on creating a telehealth follow-up process for psychiatric patients post-discharge, with Amanda Howell acting as the project manager. The key data needed are patient demographics, 30-day rehospitalization rates, and 7-day follow-up compliance rates. Data protection measures include securing data access and sharing via encrypted Excel files limited to the project team.

Progress monitoring will include weekly report reviews and visual presentations through graphs and tables. The success of the project will be evaluated by achieving complete staff training before the launch, conducting weekly audits, and ultimately reducing rehospitalization while improving outpatient compliance.

Phase 2 Task 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

Data Management Plan

What are the three primary data elements to track?

Number of project team members educated on the new telehealth process.
Psychiatric patient 30-day rehospitalization rates.
Compliance rates for 7-day post-discharge outpatient follow-up appointments.

What data sources will be used to evaluate project success?

The electronic medical record (EMR) system, linked to a comprehensive database, will be the primary source. Data will be extracted and exported into a secure Excel spreadsheet, accessible solely to authorized project members, to ensure data integrity and confidentiality.

What are the key performance indicators (KPIs) for the process?

KPI	Description
Staff Training Completion	100% of staff educated on the new telehealth process before launch
Weekly Audits	Weekly monitoring of 30-day rehospitalization and 7-day follow-up rates conducted by the project manager

What benchmarks are aligned with the SMART goal?

The project aims to improve the 7-day follow-up compliance by 5% and reduce psychiatric rehospitalizations by 2%, establishing clear, measurable targets that align with the SMART framework.

How will quantitative data be collected?

The project manager will extract patient demographic information and outcome measures from the EMR, focusing on patients discharged from the psychiatric unit. The data will track whether patients were readmitted within 30 days and whether they attended follow-up outpatient appointments within 7 days of discharge.

How will the organization protect its data?

Data protection involves strict access controls managed by the project manager. Data will be securely shared via an encrypted Excel file to prevent unauthorized access, ensuring compliance with organizational data privacy standards.

What parameters will be used to collect quantitative data?

Quantitative data collection will include variables such as:

Admission and discharge dates from the psychiatric unit.
Patient age and diagnosis.
Scheduled outpatient follow-up appointments.
Insurance or payor source.

How will high-priority data be analyzed?

The analysis method will emphasize ensuring the data’s cleanliness and accuracy. The review will focus on the predefined goals of the project, allowing for targeted insights into the effectiveness of the telehealth intervention.

How will results be interpreted?

Interpreting results will involve understanding the context surrounding the data, recognizing potential limitations and biases, and applying an objective approach to data analysis to draw valid conclusions.

What potential issues could impact the results?

Possible challenges include delays in insurance claims reporting and incomplete follow-up data if patients attend appointments outside the organization’s network. Since the project manager’s access is limited to organizational data, this could result in underreported follow-up rates.

GoReact Video Summary (Phase 2)

The critical data elements identified include team education on the telehealth process, psychiatric rehospitalization, and follow-up compliance rates. Data will be sourced from the EMR and transferred to a secured Excel sheet accessible only to the project team.

Key performance indicators focus on staff training completion and weekly audits. The SMART goal is to increase 7-day follow-up compliance by 5% and reduce rehospitalizations by 2%. Quantitative data collection parameters cover demographic and clinical details. Data analysis will prioritize accuracy and clarity, with interpretation mindful of contextual factors and limitations. Challenges such as claims delays and external follow-ups could affect data completeness.

References

Agency for Healthcare Research and Quality. (2023). Best practices in telehealth follow-up care. Retrieved from https://www.ahrq.gov/telehealth
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