QI in Clinics Pilot Application

QI in Clinics Pilot

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.

Step 1 of 3

Clinic Details

Name of Clinic(Required)

Team Details

Teams will consist of a physician(s), a medical office assistant and/or office manager, who will lead a clinic-wide improvement project. Teams can have two to five members attend the virtual workshops.

Team Member 1

Name(Required)

First Last

Preferred Name

Position Title(Required)

Phone(Required)

Email(Required)

Team Member 2

Name

First Last

Preferred Name

Position Title

Phone

Team Member 3

Name

First Last

Preferred Name

Position Title

Phone

Team Member 4

Name

First Last

Preferred Name

Position Title

Phone

Team Member 5

Name

First Last

Preferred Name

Position Title

Phone

Program/project sponsor

Who will sponsor your participation in this program?(Required)

Within the QI in Clinics program, a sponsor refers to someone who will assist reducing barriers to participating in the program and testing changes within your clinic. They may provide time-relief for you to attend the sessions or work on the project.

Project details

Quality Improvement projects are best formulated around a specific area you want to seek improvement. It could be an area that is not working well, or it could be somewhere that is functional, but you think could be even better. With that in mind, when answering the below questions please try to think of the area you are wanting to apply a quality improvement project to, rather than providing a solution to the problem.

Please tell us about the problem you are proposing to address through your participation in the QI in Clinics program. Describe how you know that this is a problem.(Required)

What would success look like in addressing this problem? For example, how would addressing this problem benefits patients and families, clinic staff or provider experience and wellbeing?(Required)

Familiarity with quality improvement

The following questions will help the program facilitators ensure the content meets the needs of all participants:

On average, what is your/your team’s level of familiarity with Quality Improvement?(Required)

What areas are you looking to gain more knowledge in? (select all that apply)(Required)

How to measure change

How to generate ideas for change

How to implement change

How to scope a QI project

How to engage patients and families in improvement work

How to interpret data from available sources (i.e., EMR data, panel report data)

What do you hope to gain from participation in the QI in Clinics program?(Required)

How would this program benefit your clinic?(Required)

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.

I agree