Student 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 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 Project Aim The purpose 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 of discharge from an acute inpatient setting. The initiative seeks to reduce avoidable psychiatric rehospitalizations while strengthening patient engagement and adherence to outpatient psychiatric care. By ensuring timely post-discharge contact, the project supports continuity of care and early identification of patient needs. Project Leadership Amanda Howell serves as the Project Manager for this initiative. In this role, she is responsible for coordinating project activities, monitoring progress, ensuring adherence to timelines, and overseeing data collection and analysis to evaluate project outcomes. Essential Data for Analysis To accurately assess the effectiveness of the telehealth intervention, several key data elements will be analyzed. These include demographic characteristics of psychiatric patients discharged from the behavioral health unit, rates of rehospitalization within 30 days of discharge, and compliance rates for outpatient follow-up appointments completed within seven days of discharge. Collectively, these data points provide insight into patient outcomes and system performance. Data Protection and Confidentiality Patient information will be accessed exclusively through a secure organizational database. Data access will be controlled by the project manager to ensure that only authorized project team members can view sensitive information. All data sharing will occur via encrypted Excel files restricted to the project team, maintaining compliance with privacy regulations and organizational data governance standards. Presentation of Results Project findings will be communicated through a combination of tables and graphical displays. These visuals will compare baseline and post-implementation data related to 30-day rehospitalization rates and seven-day follow-up appointment compliance. Presenting results in this format will facilitate clear interpretation of trends and highlight the impact of the telehealth follow-up process. Project Team Roles and Responsibilities The project manager will lead ongoing oversight of the initiative by conducting weekly reviews of data reports. These reviews will focus on monitoring rehospitalization trends and follow-up compliance rates to evaluate the effectiveness of the intervention and identify areas for improvement. Targeted Performance Metrics Metric Target Outcome Staff Training 100% completion prior to project launch Audit Frequency Weekly audits conducted by the project manager Psychiatric Rehospitalization Rates Measurable reduction in rehospitalizations Follow-Up Appointment Compliance Rates Increased attendance at outpatient appointments GoReact Video Summary – Phase 1 This phase emphasizes the development of a telehealth follow-up process for psychiatric patients after discharge. Amanda Howell oversees the project as manager. Key data elements include patient demographics, 30-day rehospitalization rates, and seven-day follow-up compliance. Data security is maintained through restricted access and encrypted file sharing. Progress is tracked through weekly data reviews and visual reporting tools, with success measured by full staff training, consistent audits, reduced rehospitalizations, and improved outpatient engagement. 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 Primary Data Elements The project will focus on three primary data elements: the number of project team members educated on the telehealth follow-up process, psychiatric patient rehospitalization rates within 30 days of discharge, and compliance rates for outpatient follow-up appointments completed within seven days. Data Sources The electronic medical record (EMR) system will serve as the primary data source for evaluating project success. Relevant data will be extracted from the EMR and transferred into a secure Excel spreadsheet that is accessible only to authorized project team members to preserve confidentiality and data integrity. Key Performance Indicators KPI Description Staff Training Completion 100% of staff educated on the telehealth process before project launch Weekly Audits Ongoing weekly monitoring of rehospitalization and follow-up compliance SMART Benchmarks The project aligns with SMART goal principles by targeting a 5% increase in seven-day outpatient follow-up compliance and a 2% reduction in 30-day psychiatric rehospitalization rates. These benchmarks are specific, measurable, achievable, relevant, and time-bound. Quantitative Data Collection Quantitative data will be collected by the project manager through systematic extraction from the EMR. Data will focus on psychiatric patients discharged from inpatient care and will track rehospitalization within 30 days and attendance at outpatient follow-up appointments within seven days. Data Security Measures To protect organizational data, strict access controls will be enforced. The project manager will oversee data sharing, which will occur only through encrypted Excel files, ensuring adherence to organizational privacy policies and regulatory requirements. Data Collection Parameters Quantitative data collection will include admission and discharge dates, patient age, psychiatric diagnosis, scheduled outpatient follow-up appointments, and insurance or payer source. These variables support comprehensive evaluation of patient outcomes and care transitions. Analysis of High-Priority Data Data analysis will prioritize accuracy, completeness, and consistency. The project manager will ensure data cleanliness before analysis and will focus on predefined project objectives to determine the effectiveness of the telehealth intervention. Interpretation of Results Results will be interpreted within the context of patient care processes and system limitations. Potential biases and data gaps will be acknowledged, and objective analytical methods will be applied to support valid and reliable conclusions. Potential Challenges and Limitations Challenges that may influence results include delays in insurance claims reporting and incomplete follow-up data when patients receive care outside the organization’s network. Because access is limited to internal data sources, some follow-up encounters may not be fully captured. GoReact Video Summary – Phase 2 Phase 2 centers on structured data management and evaluation. Key data elements include staff education, psychiatric rehospitalization rates, and follow-up compliance. Data is sourced from the EMR and secured in encrypted files. KPIs emphasize staff training completion and weekly audits, while SMART goals target improved follow-up compliance and reduced rehospitalization. Data analysis prioritizes

Student Name Western Governors University D158 Strategically Planning the Execution of a Healthcare Improvement Project Prof. Name Date D158 Healthcare Improvement Project Paper Implementation Approach What was the initial step in advancing the Healthcare Improvement Project (HIP)? A dedicated project team was established, comprising several members from the organization, to focus on reducing surgical cancellations. The project began with an initial meeting between myself and my preceptor, marking the initiation phase. This session was pivotal in defining the scope of the HIP, which was then presented to the full project team to secure their consensus and commitment. How did the team plan for the project’s execution? During the planning phase, the team held biweekly meetings to evaluate the necessary resources for successful implementation. An important deliverable from this phase was the development of a budget, meticulously calculated using a detailed personnel pay and hours spreadsheet, ensuring financial transparency and resource allocation accuracy. What consensus method was chosen for decision-making and why? For decision-making during the implementation phase, I selected the Nominal Group Technique (NGT), an effective method suitable for small groups meeting in person. NGT follows a structured four-step process: Stage Description Silent Generation Each team member independently writes down their ideas without influence. Round Robin Members sequentially share one idea each with the group. Clarification Group discusses and asks questions to elaborate on all ideas. Ranking Participants rank the ideas based on importance or relevance. This structured approach facilitated a harmonious team environment, culminating in unanimous agreement on the HIP plan. How does the project maintain momentum during implementation? To sustain progress, biweekly meetings are proposed. Meeting too often risks insufficient time for evaluating implemented changes, while less frequent meetings might reduce focus. The project manager is responsible for scheduling these meetings, creating agendas aligned with the action plan and the Gantt chart, which is regularly updated to track progress. Additionally, weekly email updates ensure consistent communication between meetings. Were any policies reviewed or updated during the project? An ongoing agenda item was the evaluation of existing policies to determine if updates were necessary. While the hospital’s exclusion criteria policy remained unchanged, modifications were made to the preadmission testing guidelines. The prior approach of a single phone call was replaced with weekly follow-up calls to enhance patient engagement. Given the overlapping membership between the project team and stakeholders, all changes were discussed and voted on during meetings, securing unanimous approval. Action Plan The action plan was developed collaboratively, detailing five critical steps, each with assigned responsibilities, phases, and target completion dates. This plan aligns closely with the accompanying Gantt chart, which breaks down each action item into specific subtasks. Phase Action Item Description Responsible Parties Target Completion Date Initiation Identify HIP goal to reduce surgical cancellations by 5% Project Manager, Preceptor 01/29/2024 Planning Determine financial resources and complete Pro Forma budget Project Manager, Preceptor, Team 04/25/2024 Implementation Educate surgical, pre-op, operating, and preadmission staff Project Manager, Preceptor, Team 06/10/2024 Control Monitor and manage budget variances Project Manager 07/31/2024 Evaluation/Closure Assess HIP outcomes and present findings to leadership Project Manager, Preceptor 07/31/2024 The project spans from January through the end of July 2024, providing structured deadlines to guide each phase and keep the team aligned. Gantt Chart Utilization What role does the Gantt chart play in the project? The Gantt chart is a dynamic planning and tracking tool that allows the project manager and team to visualize tasks, deadlines, and progress. The chart is updated collaboratively to reflect ongoing status and plan upcoming activities, reinforcing accountability. Phase Key Tasks/Subtasks Target Date Initiation Identify HIP, select stakeholders, complete needs assessment 01/30/2024 Planning Complete financial analysis and personnel budget 04/19/2024 Implementation Conduct educational sessions and process walkthroughs 06/07/2024 Control Review monthly financial reports and weekly budget updates 07/31/2024 Evaluation Analyze surgical cancellation data and prepare leadership presentation 07/29/2024 Social Determinants of Health (SDOH) and Target Population Who is the target population and what are their key social determinants? The HIP targets reducing surgical cancellations by 5% by June 30, 2024, at Ortho Colorado Hospital (OCH) in Lakewood, Colorado—a 48-bed facility with 17 pre-op/PACU bays and 8 operating rooms, staffed by 187 employees (175 clinical). The target population reflects diverse sociodemographic characteristics: Factor Description Population Lakewood population: 156,149 (2022) Median Age 38.1 years Median Household Income $82,786 Ethnicity White Non-Hispanic (68.2%), Hispanic (7.42%), Asian Non-Hispanic (3.89%), African American (1.6%) Veteran Status 5.25% of population Education Level Bachelor’s degree (20.8%), Some college (12.5%), High school diploma (14.8%) Insurance Coverage Uninsured rate slightly rose from 7.38% to 7.54% (2021-2022) Poverty Rate 8.8% living below poverty level How are social determinants addressed in the project? The project empowers patients with clear expectations and education to reduce anxiety and boost confidence, supplemented by weekly preadmission nurse calls to reinforce engagement and trust. Force Field Analysis What are the driving and restraining forces influencing the HIP implementation? Driving Forces Restraining Forces 1. Persistent rise in surgical cancellations 1. Resistance from surgeon’s office leadership due to increased workload 2. Strong executive leadership support 2. Difficulty maintaining accountability among clinic staff 3. Approved budget for additional preadmission staff 3. Staffing shortages limiting communication capacity What strategies are planned to address these forces? Scope Statement The improved process focuses on enhancing patient engagement via multiple phone touchpoints and the creation of educational materials such as handouts, booklets, or classes. These resources aim to clarify surgical requirements and milestones, facilitating patient understanding and compliance throughout their surgical journey. SMART Goal The project’s SMART objective is to achieve a 5% reduction in surgical cancellations at Ortho Colorado Hospital by June 30, 2024. This goal will be realized by improving patient communication through increased touchpoints, comprehensive educational materials, and targeted staff education. Project Timeline Start Date End Date HIP Duration 01/29/2024 07/31/2024 Key Performance Indicators (KPIs) KPI Description Target/Deliverable 1. Develop and implement educational materials and preadmission screening with staff competency sign-off Completion by June 10, 2024 2. Achieve 100% compliance with preadmission checklist by surgeon’s clinic and preadmission staff Checklist deployed by

Student Name Western Governors University D158 Strategically Planning the Execution of a Healthcare Improvement Project Prof. Name Date Strategically Planning the Execution of a Healthcare Improvement Project What are the essential tasks and timelines in the preparation phase of the Clinical Practice Experience (CPE)? The preparation phase of the Clinical Practice Experience (CPE) lays the groundwork for a well-structured and successful healthcare improvement project. It begins with an initial meeting with the preceptor to comprehensively review the CPE requirements, ensuring that all expectations are clearly understood by all participants. Following this, a detailed schedule is formulated, outlining specific tasks and timelines to ensure systematic progress throughout the project. An important activity during this phase is conducting a force field analysis with the project team. This tool helps identify the driving and restraining forces that could impact the project’s success. Insights from this analysis are then discussed with the preceptor to refine understanding and strategize accordingly. To facilitate reflective learning and peer interaction, a GoReact video is created to document the phase’s progress. The participant also reviews two peer videos and provides constructive feedback, enhancing collaborative learning. The phase concludes with a written reflection summarizing key observations and lessons learned during the preparation. These preparatory activities are critical for recognizing potential challenges and supports within the project environment, while also establishing a timeline that integrates clinical and educational objectives. Peer engagement fosters critical appraisal skills and collaborative learning, which are indispensable in healthcare improvement projects (Kotter, 2012). Preparation Phase Tasks and Timeline Task Description Estimated Time Due Date Meet with preceptor to review CPE requirements 1 hour 09/15/2025 Develop CPE schedule table with tasks and timelines 1 hour 09/15/2025 Conduct force field analysis with project team 4 hours 09/16/2025 Discuss force field analysis findings with preceptor 1 hour 09/16/2025 Create GoReact video; review 2 peer videos; provide feedback 1 hour 09/16/2025 Write reflection summary on Phase 1 video reflection 2 hours 09/16/2025 How is the Gantt chart employed in the project planning phase, and what specific tasks are involved? In the second phase of the healthcare improvement project, detailed scheduling becomes the primary focus, achieved through the creation of a Gantt chart. This chart serves as a visual project timeline that allows the team to allocate resources effectively, establish clear milestones, and monitor progress in a structured manner. Collaboration with the project team during this stage is essential to ensure all tasks, dependencies, and deadlines are accurately captured. After drafting the Gantt chart, it is reviewed with the preceptor to validate the project timeline and make necessary adjustments. As in the previous phase, a GoReact video is produced to showcase progress and insights gained. The participant reviews peer videos and offers feedback, which encourages reflective learning and teamwork. The phase culminates in a written reflection, which deepens understanding of project management principles and adherence to the schedule. The use of a Gantt chart aligns with recognized project management best practices, aiding in breaking down complex projects into manageable segments, optimizing resource distribution, and mitigating risks (Project Management Institute [PMI], 2021). The iterative cycle of review and reflection helps participants develop adaptive project management skills and enhances team collaboration. Project Planning Phase Tasks and Timeline Task Description Estimated Time Due Date Collaborate with project team to develop Gantt chart 5 hours 09/18/2025 Complete the Gantt chart 5 hours 09/18/2025 Review the Gantt chart with preceptor 1 hour 09/18/2025 Create GoReact video; review 2 peer videos; provide feedback 1 hour 09/18/2025 Write reflection summary on Phase 2 video reflection 2 hours 09/18/2025 References Kotter, J. P. (2012). Leading change. Harvard Business Review Press. Project Management Institute. (2021). A guide to the project management body of knowledge (7th ed.). PMI.