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QI in Clinics: Apply for cohort 1, 2 or 3

QI in Clinics Cohort 1, 2, 3

Please complete this form to express you/your team’s intent to participate in the pilot of the QI in Clinics program and to help guide you in your project selection.

Clinic Details

Which cohort of QI in Clinics are you applying to?(Required)

Team Details

QI in Clinics is designed to build capacity for quality improvement with a team working in a primary health-care clinic. Teams should consist of a minimum one physician, a medical office assistant and/or office manager, who will lead a clinic-wide improvement project. Clinics may be eligible to have up to five members reimbursed for participating in the program. All team members are expected to take part in both the online course and the virtual workshops. (Please see the QI in Clinics program guide for further details on team member composition, funding available, and associated program expectations.)

Team Member 1 - this person is the primary contact for your team

Name(Required)
Are you eligible for Mainpro+ credits?(Required)

Team Member 2

Name(Required)
Are you eligible for Mainpro+ credits?(Required)

Team Member 3

Name
Are you eligible for Mainpro+ credits?

Team Member 4

Name
Are you eligible for Mainpro+ credits?

Team Member 5

Name
Are you eligible for Mainpro+ credits?

Program sponsor

QI projects within clinics are best supported with sponsorship from the clinic owner or manager. The program sponsor supports and enables participants to take part in the learning components of the program as well as implement their QI project work. The sponsor removes barriers and supports project progress by championing and encouraging other clinic staff to take part in testing and implementing changes.
Name

Project details

Teams are required to apply their learning to a QI project within their clinic. QI projects may be focused on any area for improvement within the clinic, and may include a focus on patient outcomes, patient experience, staff experience/well-being, and/or clinic processes.

Familiarity with quality improvement

The following questions will help the program facilitators ensure the content meets the needs of all participants:
I agree that, if accepted into the program, my name, organization name, organization logo, and images of myself can be used in promotional materials on the QI in Clinics web page, social media posts, and other promotional materials.