D159 CPE Record: Leadership and Management E-Portfolio Template

Grace J.
January 3, 2026January 3, 2026
D159, MSN, Western Governors University

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 of the Leadership and Management E-Portfolio focuses on foundational planning, documentation, and initial project conceptualization. The tasks completed during this phase establish the framework for effective project implementation and evaluation.

Table 1
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

Project Report Plan

What Is the Project Aim?

The primary aim of this project is to design and implement a structured telehealth follow-up process in which nurse case managers contact psychiatric patients within seven days following discharge from an acute behavioral health hospitalization. This initiative seeks to strengthen continuity of care, enhance patient engagement in outpatient psychiatric services, and ultimately reduce 30-day psychiatric rehospitalization rates. Early post-discharge contact has been shown to support treatment adherence and mitigate relapse risk during a highly vulnerable transition period.

Who Is the Project Manager?

Amanda Howell serves as the Project Manager for this initiative. In this leadership role, she is responsible for coordinating project activities, ensuring adherence to timelines, overseeing data collection and analysis, and facilitating communication among stakeholders. Her responsibilities also include monitoring performance metrics and guiding continuous quality improvement efforts.

Essential Data for Analysis

What Data Are Essential for Evaluating Project Outcomes?

To accurately evaluate the effectiveness of the telehealth follow-up intervention, several critical data elements will be collected and analyzed. These data points support both outcome measurement and process evaluation.

Key data elements include demographic characteristics of psychiatric patients discharged from the behavioral health unit, 30-day rehospitalization rates, and the percentage of patients who complete an outpatient psychiatric follow-up appointment within seven days of discharge. Collectively, these indicators allow for assessment of both patient outcomes and system-level performance.

Data Security and Confidentiality

How Will Patient Data Be Protected?

Patient data will be accessed exclusively through a secure organizational database that complies with healthcare privacy regulations. Access permissions will be tightly controlled by the project manager, ensuring that only authorized project team members can view or handle sensitive information. Data extracted for analysis will be stored in an encrypted Excel file housed on a secure network. This approach minimizes the risk of unauthorized access while maintaining compliance with institutional policies and regulatory standards such as HIPAA.

Data Presentation and Reporting

How Will Project Results Be Presented?

Project findings will be communicated using both graphical and tabular formats to support clarity and stakeholder understanding. Comparative charts will illustrate changes in 30-day rehospitalization rates and 7-day follow-up compliance before and after implementation of the telehealth intervention. Tables will provide precise numerical comparisons, enabling leadership to quickly assess trends, progress, and areas requiring improvement.

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, who assumes primary responsibility for oversight and evaluation. Weekly data reviews will be conducted to monitor 30-day psychiatric rehospitalization rates and 7-day follow-up appointment compliance. These reviews enable timely identification of barriers, support accountability, and inform any necessary adjustments to the intervention strategy.

Targeted Performance Metrics

What Metrics Will Be Used to Measure Success?

Specific performance metrics have been identified to evaluate both implementation fidelity and project outcomes. These metrics align with quality improvement principles and organizational goals.

Table 2
Targeted Project Metrics

Metric	Target Outcome
Staff Training	100% of relevant staff trained prior to project launch
Audit Frequency	Weekly audits conducted by the project manager
Psychiatric Rehospitalization	Measurable reduction in 30-day rehospitalization rates
Follow-Up Appointment Compliance	Increase in 7-day outpatient appointment attendance

GoReact Video Summary (Phase 1)

The Phase 1 GoReact video emphasized the development of a telehealth-based follow-up process for psychiatric patients transitioning from inpatient to outpatient care. The project manager’s role was highlighted as central to data oversight, staff engagement, and outcome evaluation. Key data elements include patient demographics, rehospitalization rates, and follow-up compliance metrics. Secure data management practices and regular progress monitoring through weekly audits were identified as essential components of project success.

Phase 2 Task Overview

Phase 2 builds upon the planning foundation established in Phase 1 and emphasizes structured data management, performance tracking, and outcome evaluation.

Table 3
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

Data Management Plan

What Are the Three Primary Data Elements to Track?

The project focuses on three essential data elements: the number of project team members educated on the telehealth follow-up process, 30-day psychiatric rehospitalization rates, and patient compliance with outpatient follow-up appointments completed within seven days of discharge. These data elements collectively assess readiness, implementation effectiveness, and patient outcomes.

What Data Sources Will Be Used to Evaluate Project Success?

The electronic medical record (EMR) system will serve as the primary data source. Relevant data will be extracted from the EMR and transferred into a secure Excel spreadsheet. Access to this file will be restricted to authorized project team members to preserve data integrity and confidentiality.

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 telehealth process education prior to launch
Weekly Audits	Ongoing monitoring of rehospitalization and follow-up compliance rates

What Benchmarks Align With the SMART Goal?

The project benchmarks are aligned with SMART criteria by targeting a 5% increase in 7-day outpatient follow-up compliance and a 2% reduction in psychiatric rehospitalization rates. These benchmarks are specific, measurable, achievable, relevant, and time-bound, supporting meaningful performance evaluation.

Quantitative Data Collection and Analysis

How Will Quantitative Data Be Collected?

Quantitative data will be collected through systematic extraction from the EMR by the project manager. Data collection will focus on patients discharged from the psychiatric unit and will include readmission status within 30 days and completion of follow-up appointments within seven days.

What Parameters Will Be Used for Data Collection?

Key parameters include admission and discharge dates, patient age, psychiatric diagnosis, scheduled outpatient follow-up appointments, and insurance or payor source. These variables support stratified analysis and identification of trends affecting patient outcomes.

How Will High-Priority Data Be Analyzed and Interpreted?

Data analysis will prioritize accuracy, completeness, and relevance to the project goals. Interpretation will account for contextual factors, potential biases, and known data limitations. Findings will be evaluated objectively to determine the effectiveness of the telehealth intervention and guide future quality improvement efforts.

Potential Challenges and Limitations

What Issues Could Impact Project Results?

Several challenges may influence data completeness and outcome interpretation. Delays in insurance claims processing may affect rehospitalization reporting, while follow-up appointments completed outside the organization’s network may not be captured in the EMR. These limitations will be acknowledged during analysis to ensure transparent and responsible reporting.

GoReact Video Summary (Phase 2)

The Phase 2 GoReact summary reinforced the importance of structured data management and performance monitoring. Emphasis was placed on tracking staff education, rehospitalization rates, and follow-up compliance. The SMART-aligned benchmarks, secure data handling procedures, and recognition of potential data gaps were identified as critical factors influencing project validity and sustainability.

References

Agency for Healthcare Research and Quality. (2023). Best practices in telehealth follow-up care. 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

World Health Organization. (2021). Data protection and privacy in healthcare. https://www.who.int/data-protection-healthcare