D159 CPE Record: Leadership and Management E-Portfolio Template

Leadership and Management E-Portfolio Template

The Leadership and Management E-Portfolio documents the planning, implementation, monitoring, and evaluation of a telehealth quality improvement project for patients transitioning from acute behavioral health hospitalization to outpatient psychiatric care. The project focuses on completing a follow-up contact within seven days of discharge, improving continuity of care, increasing engagement with outpatient services, and monitoring 30-day psychiatric rehospitalization rates. Effective leadership, secure data management, routine performance monitoring, and clearly defined outcome measures are essential to evaluating the project.

Phase 1 Task Overview

Phase 1 establishes the foundation for the leadership and management e-portfolio project. The work includes project planning, documentation, development of the project report, and preparation of GoReact video presentations. Completing these activities provides a structured framework for implementation and creates a basis for evaluating project outcomes.

Phase 1 Task Completion

Project Report Plan

What Is the Aim of the Project?

The primary aim of the project is to develop and implement a structured telehealth follow-up protocol for psychiatric patients discharged from acute behavioral health hospitalization. Under the proposed process, nurse case managers will contact patients within seven days after discharge to support continuity of care and encourage engagement with outpatient psychiatric services.

Early post-discharge follow-up is particularly important because patients transitioning from inpatient behavioral health care may experience barriers to medication adherence, appointment attendance, care coordination, and ongoing treatment. Monitoring follow-up completion and 30-day rehospitalization can help the organization evaluate whether the intervention is achieving its intended quality improvement objectives.

Who Is the Project Manager?

Amanda Howell serves as the Project Manager and is responsible for coordinating the major activities associated with the initiative. Her responsibilities include monitoring project timelines, coordinating team communication, overseeing data collection, reviewing project performance, and supporting the evaluation of outcomes.

The project manager also facilitates continuous quality improvement by identifying implementation barriers, reviewing performance data, and helping the team determine whether process changes are needed.

Essential Data for Project Evaluation

What Data Are Needed to Evaluate the Project?

Several data elements are necessary to evaluate the effectiveness of the telehealth follow-up process. These include patient demographic characteristics, completion of outpatient psychiatric follow-up within seven days of discharge, and psychiatric rehospitalization within 30 days.

Together, these measures provide information about both process performance and patient outcomes. Follow-up attendance indicates whether the new process is being implemented as intended, while rehospitalization data provide an outcome measure that can be monitored over time.

How Will Patient Data Be Protected?

Patient information will be accessed through a secure organizational database and handled according to applicable privacy and security requirements, including HIPAA requirements where applicable. Access should be limited to authorized personnel whose responsibilities require access to project information.

Extracted data should be stored using approved organizational systems with appropriate access controls, encryption, authentication, and secure data-transfer practices. Identifiable patient information should also be minimized whenever it is not necessary for the project.

Protecting patient confidentiality is an important component of healthcare quality improvement because inappropriate disclosure of protected health information can create privacy, legal, and organizational risks.

Data Presentation and Reporting

How Will Project Results Be Presented?

Project results will be presented using tables and visual displays to make performance trends easier for stakeholders to understand. Graphs can be used to compare 30-day psychiatric rehospitalization rates before and after implementation, while tables can summarize seven-day follow-up completion rates and other relevant measures.

Clear data presentation allows project leaders and stakeholders to identify changes over time, recognize potential barriers, and determine whether additional quality improvement actions are necessary.

Project Team Roles and Responsibilities

What Are the Roles of the Project Team?

The project manager, Amanda Howell, leads the project and coordinates implementation, data review, communication, and evaluation activities. Other members of the project team contribute to patient follow-up, documentation, data collection, staff education, and monitoring.

Weekly reviews of 30-day rehospitalization rates and seven-day outpatient follow-up compliance provide an opportunity to identify problems early. Regular team communication also promotes accountability and supports timely adjustments when performance does not meet established targets.

Targeted Performance Metrics

How Will Project Success Be Measured?

The project uses key performance indicators to evaluate both implementation and outcomes. These measures address staff preparedness, monitoring frequency, outpatient follow-up, and psychiatric rehospitalization.

These indicators allow the project team to determine whether the intervention is being implemented consistently and whether measurable changes are occurring in patient follow-up and rehospitalization outcomes.

GoReact Video Summary: Phase 1

The Phase 1 GoReact presentation focused on developing a telehealth follow-up process for psychiatric patients transitioning from inpatient behavioral health care to outpatient services. The presentation emphasized the project manager’s responsibilities for coordinating implementation, monitoring data, engaging staff, and evaluating outcomes.

The presentation also highlighted the importance of secure patient-data management and regular performance audits. Consistent monitoring provides the project team with information needed to identify barriers and support continuous quality improvement.

Phase 2 Task Overview

Phase 2 builds on the planning completed during Phase 1 by focusing on data management, performance monitoring, quantitative analysis, and evaluation of project outcomes. This phase provides a systematic approach for determining whether the telehealth follow-up intervention is meeting its established objectives.

Phase 2 Task Completion

Data Management Plan

What Are the Three Primary Data Elements?

The project focuses on three primary measures: completion of staff training, 30-day psychiatric rehospitalization, and completion of outpatient psychiatric follow-up within seven days after discharge.

Staff training measures organizational readiness and implementation fidelity. Seven-day follow-up measures whether patients successfully connect with outpatient services after discharge. Thirty-day rehospitalization provides an outcome measure that can be monitored as the project progresses.

Together, these measures provide a balanced view of whether the intervention is being implemented and whether the desired outcomes are occurring.

What Data Sources Will Be Used?

The electronic medical record (EMR) is the primary source of patient-related project data. Relevant information can be extracted from the EMR and entered into an approved, secure data-management system for analysis.

If an Excel spreadsheet is used, it should be stored in an organizationally approved secure location with access restricted to authorized project personnel. The project team should follow organizational policies for data retention, access, storage, and disposal.

Key Performance Indicators and Benchmarks

What Are the Key Performance Indicators?

The primary key performance indicators include staff training completion and weekly monitoring of follow-up and rehospitalization measures.

These indicators help the project team monitor whether the intervention is being implemented according to plan and whether performance changes require additional intervention.

What Benchmarks Support the SMART Goal?

The project establishes measurable benchmarks of a 5% increase in seven-day outpatient follow-up attendance and a 2% reduction in psychiatric rehospitalization rates. These targets provide specific measures that can be tracked during the project period.

A SMART goal should be specific, measurable, achievable, relevant, and time-bound. Establishing defined benchmarks makes it possible to compare actual performance with the desired outcomes and determine whether the project is progressing as expected.

Quantitative Data Collection and Analysis

How Will Quantitative Data Be Collected?

The project manager will systematically collect quantitative information from the EMR for eligible psychiatric patients discharged from the unit. The primary measures will include whether patients were rehospitalized within 30 days and whether they completed an outpatient psychiatric appointment within seven days of discharge.

Consistent data-collection procedures are important because changes in definitions, eligibility criteria, or documentation practices can affect the reliability of comparisons over time.

What Parameters Will Be Used?

Relevant data parameters may include admission and discharge dates, patient age, psychiatric diagnosis, outpatient appointment information, and insurance or payer information when appropriate to the project.

These variables can support more detailed analysis by allowing the team to examine whether particular patient or system characteristics are associated with differences in follow-up or rehospitalization outcomes.

How Will High-Priority Data Be Analyzed?

The project team will review quantitative data for accuracy, completeness, relevance, and consistency. Results should be interpreted within the context of the project design and should account for limitations that could affect the findings.

The analysis should distinguish between changes observed after implementation and changes that can be directly attributed to the intervention. Reviewing contextual factors and potential sources of bias helps ensure that project findings are reported responsibly.

Potential Challenges and Limitations

What Factors Could Affect Project Results?

Several factors may affect the accuracy or completeness of the project data. For example, insurance claims or external healthcare records may not be available immediately, which could delay identification of rehospitalizations. Similarly, patients who receive outpatient services or are rehospitalized outside the organization’s network may not have those encounters documented in the organization’s EMR.

These limitations should be documented when results are reported. Acknowledging missing or incomplete data allows stakeholders to interpret findings appropriately and reduces the risk of overstating the project’s impact.

Other potential considerations include differences in documentation practices, changes in staffing, patient participation, appointment availability, transportation barriers, and other factors that may influence follow-up attendance.

GoReact Video Summary: Phase 2

The Phase 2 GoReact presentation emphasized the importance of systematic data management and ongoing performance monitoring. The project tracks staff training, seven-day outpatient follow-up, and 30-day psychiatric rehospitalization as core indicators of implementation and patient outcomes.

The presentation also reinforced the importance of protecting patient information, maintaining consistent data-collection procedures, conducting routine audits, and recognizing potential gaps in the available data. These practices strengthen the reliability of project evaluation and support evidence-informed quality improvement.

Leadership and Management Considerations

Why Are Leadership and Data Management Important to the Project?

Effective leadership provides direction, accountability, and coordination throughout the quality improvement process. The project manager connects the project team with organizational goals, monitors progress, communicates expectations, and facilitates responses to performance gaps.

Data management is equally important because project decisions depend on accurate and appropriately protected information. A structured process for collecting, storing, analyzing, and reporting data allows leaders to evaluate whether the intervention is producing meaningful changes and where additional improvement may be needed.

Conclusion

The leadership and management e-portfolio provides a structured framework for planning and evaluating a telehealth follow-up intervention for psychiatric patients after behavioral health hospitalization. The project combines leadership responsibilities, staff preparation, secure data management, performance monitoring, and quantitative outcome evaluation.

By monitoring seven-day outpatient follow-up and 30-day psychiatric rehospitalization, the project team can assess implementation and identify opportunities for continued improvement. Clear performance measures, consistent data practices, and transparent reporting are essential for supporting sustainable quality improvement and continuity of behavioral healthcare.

References

Agency for Healthcare Research and Quality. (n.d.). Telehealth. U.S. Department of Health and Human Services. https://www.ahrq.gov/telehealth/index.html

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

Substance Abuse and Mental Health Services Administration. (2020). National guidelines for behavioral health crisis care: Best practice toolkit. U.S. Department of Health and Human Services. https://www.samhsa.gov/

D159 CPE Record: Leadership and Management E-Portfolio Template

U.S. Department of Health and Human Services. (n.d.). Health information privacy. https://www.hhs.gov/hipaa/index.html

World Health Organization. (2021). Global strategy on digital health 2020–2025. https://www.who.int/publications/i/item/9789240020924