NURS 718 Week 8 HMIS Project Part 3 on Implementation and Evaluation Example

HMIS Project Part 3, Implementation and Evaluation: Taking a Telestroke Network Live, Measuring It Against Its Goals and Keeping It Running

Abstract

At the two smaller hospitals of a rural health system in the Shenandoah Valley, stroke patients have relied on telephone advice from neurologists who cannot see them, and last year 31 were transferred, many without treatment. The project proposed connecting each hospital's emergency department by video to the neurologists of a comprehensive stroke center, with the vision that every stroke patient will be seen by a specialist within 15 minutes of arrival. Part 1 committed the network to five goals covering how quickly a specialist appears, how quickly treatment follows, how many eligible patients are treated, how many transfers are avoided and how well staff are prepared. Part 2 planned governance, requirements, workflow, partner selection, security, training, a $650,000 budget, risks and a twelve-month timeline. Part 3 presents the implementation, organized by Kotter's eight steps, with a readiness checklist, a go-live plan, a stabilization period, an evaluation using structure, process, outcome and balancing measures, and a plan for sustaining and later extending the network.

Introduction

The first two parts of this project described why Shenandoah Valley Health needs a telestroke network and how it should be built. This final part explains how the network will be put into operation and how the organization will know whether it is working. Tan and Payton (2010) describe implementation as the stage at which a planned system meets the realities of the organization, and they caution that many systems fail at this stage not because of technical faults but because people, processes and the organization's culture were not prepared. The plan therefore gives as much attention to leading the change as to installing the equipment, and it defines the evaluation in enough detail that the stroke coordinator could begin collecting data tomorrow. Nothing in this plan should come as a surprise to the people it affects; each step has been discussed with the site nurse champions and the physician champion during planning.

Leading the Change

A telestroke network changes who makes decisions, how emergency nurses spend the first hour of a stroke alert and how the smaller hospitals relate to the stroke center. Changes of this kind need deliberate leadership. Kotter (2012) sets out an eight-stage process for leading organizational change. Leaders first make the need for change felt and assemble a team with enough authority to drive it. They then shape a vision and strategy and communicate it repeatedly, clear the obstacles that stop people from acting on it and arrange visible wins early. In the final stages they build on those wins to extend the change and root the new way of working in the organization's culture. The model fits this project because its early steps were partly completed in Parts 1 and 2 and its later steps address the period after go-live, which is when many projects lose momentum.

Urgency and Coalition

Urgency will come from our own patients. At the first staff meetings, the physician champion will present the case of the carpenter described in Part 1, along with last year's transfer figures and the evidence that telephone-only neurology access is associated with higher stroke mortality than in-person care (Shi et al., 2026). The guiding coalition is the project team named in Part 2, with the chief nursing officer as executive sponsor. Its credibility rests on the presence of frontline clinicians, the site nurse champions and the emergency physician at the community hospital, alongside leaders.

Vision and Communication

The one-sentence vision from Part 1 will appear on every cart, on the stroke alert card and at the top of every monthly report. Communication will follow the plan in Part 2: staff meetings, monthly one-page updates and a feedback form on each cart. Leaders will repeat the vision in every forum because, as Kotter (2012) argues, a vision is under-communicated far more often than it is over-communicated.

Removing Barriers and Early Wins

The barriers most likely to slow adoption are a habit of transferring without consultation, uncertainty about who is responsible for the decision, and anxiety about the technology. The order set, the shared decision protocol and simulation training address these. Early wins will be identified and shared: the first patient treated locally after a video consultation, the first month in which every alert had a consultation within 15 minutes, and the first case in which the downtime procedure worked as designed. Each will be described in the monthly update, with the patient's privacy protected.

Consolidating and Anchoring

After the first six months, the project team will hand daily operations to the stroke coordinator and the emergency department managers, and the steering committee will review the network as a standing program rather than a project. The network will be anchored in the culture by building it into orientation for new emergency staff, the annual competency program, the stroke center's quality reports to the board and the job descriptions of the stroke coordinator and site champions. A system is not implemented on go-live day; it is implemented on the day nobody remembers how stroke care worked before it.

Readiness Assessment

Go-live will not proceed until the conditions below are met. The project lead and technical lead will review the checklist with the steering committee two weeks before the planned date, and any item not met will either be completed or accepted as a documented risk by the executive sponsor.

If a readiness criterion cannot be met in time, the plan allows a delay of up to four weeks without changing the overall timeline, since the stabilization period has room built in. A delay beyond four weeks will be reported to the board with a revised schedule. Proceeding without trained staff or without the redundant connection at the critical access hospital will not be accepted as a documented risk, because both directly affect patient safety.

Go-Live Plan

All three emergency departments will go live in the same week, a choice explained in Part 2 by the small number of sites and the commitment that the critical access hospital, which serves the poorest part of the region, will not wait. A temporary command center at the regional medical center will be staffed for sixteen hours a day during the first week, beginning at seven each morning, with telephone coverage through the night.

Every stroke alert in the first month will be reviewed within 24 hours by the stroke coordinator, using a short form that records the times, any technical problem, whether the workflow was followed and what the team would change. Issues will be sorted into three groups: those that threaten patient safety, which are escalated to the project lead and the partner at once; those that slow the workflow, which are fixed within a week; and suggestions, which are considered at the monthly review.

Stabilization and Physician Engagement

The three months after go-live are the stabilization period. Huddles will move from twice daily to weekly, and the project team will hold a monthly joint case review with the partner's neurologists, which Part 2 built into the contract. Lessons from record transitions apply here. When Brunner et al. (2026) gathered nursing perspectives from three health systems that had changed electronic records, nurses recommended that organizations write their own guidance rather than rely on the vendor's, pace education to staff readiness, involve nurses in redesigning workflow and give nurses a voice in the governance of later changes. The site nurse champions will therefore remain part of the network's governance after the project ends, and changes to the stroke alert or order set will require their review.

Physician adoption is the largest risk named in Part 2. Some emergency physicians may continue to transfer patients without a consultation because that has always been the safest choice when no specialist is available. The physician champion will review every transfer without a consultation with the physician involved, not to criticize but to learn why, and the reasons will be reported to the steering committee each month. If physicians cite specific concerns, such as uncertainty about who manages a patient after thrombolysis, the protocols will be adjusted. Hospitalists at the community and critical access hospitals will be included in these conversations, because a patient treated locally becomes their patient within hours. A one-page guide to post-thrombolysis care, covering blood pressure targets, neurological checks and when to call the stroke center, will be placed in every admission packet, and the partner's neurologists will be available by video for questions during the first 24 hours of any admission after treatment. Physicians who use the network well will be asked to describe their cases at medical staff meetings, since peers are often more persuasive than project leaders.

Evaluation Plan

Evaluation determines whether the network achieved its goals and whether it should continue, change or grow. Tan and Payton (2010) treat evaluation as an ongoing part of the life cycle that informs adaptation, and Donabedian's framework provides a structure for organizing measures of quality into structure, process and outcome (Donabedian, 1988). A fourth category, balancing measures, captures unintended effects elsewhere in the system.

Methods of Analysis

Because each hospital will see only a few stroke patients a month, standard statistical comparisons will have little power in the first year. Process measures will therefore be tracked on run charts. A run chart plots each month's value in time order around a median line, and a few simple probability-based rules let the team tell a genuine change apart from the normal ups and downs of the data without advanced statistics (Perla et al., 2011). Run charts suit small numbers and can be updated by the stroke coordinator each month without specialist software. Baseline data from the twelve months before go-live will be shown on the same charts, so any shift is visible. Outcome measures will be compared before and after go-live each year, with the caution that small numbers make the comparisons imprecise.

Avoidable transfers will be judged by a structured chart review. Two reviewers, one from our emergency departments and one of the partner's neurologists, will independently classify each transfer as necessary, possibly avoidable or avoidable using criteria agreed before go-live, and disagreements will be resolved by discussion. The same criteria will be applied to the baseline year's 31 transfers, so the comparison is fair.

Equity and Balancing Measures

All measures will be reported separately for each hospital. Shen et al. (2026) showed that stroke system growth can widen income-related gaps in rural care when it reaches wealthier communities first, so the network's effect at the critical access hospital, which serves the poorest area, will be watched closely. Balancing measures matter as well. Telehealth can quietly shift effort onto nurses. Nieuwenhuys et al. (2026) found that heart failure patients under remote management needed roughly twice as many nurse practitioner contacts and minutes as usual-care patients, yet readmissions did not differ. The time emergency nurses spend on each consultation and their overtime will be tracked so that staffing can be adjusted if the network adds work.

Decision Points

The steering committee will formally review the network at six and twelve months against decision rules agreed in advance. If consultations start within 15 minutes for most alerts, door-to-needle times are falling toward the 60-minute target and no safety signal has appeared, the network will continue unchanged and planning for the second phase will begin. If process measures have not improved, the committee will ask why, examining training, workflow and partner response before considering any other step. If a safety concern emerges, such as an unexpected rate of symptomatic hemorrhage, the partner and the medical staff will review every case and the committee may suspend thrombolysis at the smaller hospitals until the cause is understood. Stating these rules before results arrive protects the evaluation from the temptation to interpret data in whatever way supports continuation.

Reporting Results

Results will reach different audiences in different forms. Frontline staff will see a one-page monthly dashboard posted in each emergency department showing consultation start times, door-to-needle times and the number of patients treated locally, with a short story about one case. The steering committee will receive the full set of measures monthly, and each quarter the board's quality committee will get a summary that includes the balancing measures and any safety concerns. The partner will receive the same data the steering committee sees, so that joint case reviews start from shared facts. At twelve months, the project lead will prepare a written evaluation report that compares each goal with its target, explains any shortfall and recommends the next step, and an abstract of the findings will be shared with the state's stroke coordinating program.

Sustaining the Network

Many telestroke programs struggle to sustain themselves once start-up funding and attention fade. In a survey of 89 hospitals, the guidance hospitals most wanted concerned monitoring process measures, using indicators for improvement and sharing data with physicians, and the authors noted that more work is needed on what threatens the sustainability of telestroke programs (Shea et al., 2022). Our plan addresses sustainability in four ways. First, the recurring cost of about $380,000 will move from the capital project into the emergency department and stroke program operating budgets in year two, with the finance office tracking avoided transfers and retained admissions as offsets. Second, the stroke coordinator role is permanent, so someone owns the data and the daily operation. Third, training is built into orientation and annual competencies, with a simulated alert each month at each site. Fourth, the partner contract will be reviewed annually against the performance standards, and renewal will depend on the evaluation results.

Legal, Regulatory and Ethical Considerations

Several requirements must be met for the network to operate lawfully and ethically. The partner's neurologists must be licensed in our state and credentialed at each hospital, which the proxy credentialing agreement accomplishes. Patients or their representatives will be told that a remote specialist is participating in their care, and the consultation will be documented in the record like any other. Privacy and security safeguards, including encryption, access controls and the business associate agreement, were set out in Part 2 and will be audited annually. The compliance officer will confirm that consultations are billed correctly under current telehealth rules, which change frequently. The ethical principle underlying all of these is respect for the patient: a remote examination must meet the same standard as an in-person one, and the plan's requirement for video, rather than telephone, in every consultation reflects that standard.

Second Phase: Inpatient Telestroke

If the first year meets its goals, the network will be extended to inpatient care at the community hospital, so that patients treated locally can stay there with specialist oversight. Evidence supports this step. In a prospective study of 1,237 patients at primary stroke centers without vascular neurologists, stroke-trained telemedicine nurse practitioners from a comprehensive stroke center documented stroke severity within 12 hours and stroke mechanism more often than community neurologists and ordered recommended cardiac monitoring more often (Dusenbury et al., 2026). Implementation lessons are available as well: clinicians in an inpatient telestroke program valued specialist access and fewer transfers but reported communication gaps between teams and a need to empower bedside nurses (Pestka et al., 2024). The second phase will be planned using the same life cycle and evaluated with the same framework.

The DNP's Role

Throughout implementation, the DNP-prepared project lead links the clinical, technical and organizational sides of the system. Zaccagnini and White (2017) expect DNP graduates to lead with information technology and to evaluate practice changes rigorously. In this project, that role includes chairing the evaluation group, presenting results to the board, ensuring that nursing workflow and workload are part of every decision, and modeling honest reporting of results that are disappointing as well as those that are encouraging.

Christian Worldview

Jesus commended the servant who was faithful in small matters, and promised that such a servant would be entrusted with more (English Standard Version Bible, 2001/2016, Luke 16:10). The network will be judged by faithfulness in small matters: a cart charged and ready at 3 a.m., a time stamp recorded accurately, a transfer reviewed honestly. Those details determine whether a patient in a small town receives the same chance of recovery as a patient near a city hospital. Implementation and evaluation are where the vision of Part 1 becomes either real care or an unkept promise, and the plan's measures and decision rules are a way of keeping that promise accountable.

Conclusion

This implementation plan takes the telestroke network from approval to sustained operation. Kotter's eight steps guide the human side of the change; a readiness checklist and a day-by-day go-live plan prepare the three hospitals; a stabilization period with case review and physician engagement addresses adoption; and an evaluation built on structure, process, outcome and balancing measures, analyzed with run charts and reported by hospital, tests each goal from Part 1. Decision rules for the six- and twelve-month reviews, a sustainment plan and a second phase for inpatient care complete the plan. Together, the three parts of the project describe a system that could bring stroke specialists to every patient in the region within minutes.

References

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