Community QI Collective Cohort 5 Application

Organization Details

Name of Organization(Required)

Which cohort are you applying for?(Required)

Team Details

Team Member 1

Name(Required)

First Last

Position Title(Required)

Phone(Required)

Email(Required)

Add Additional Team Members?

Team Member 2

Name(Required)

First Last

Position Title(Required)

Phone(Required)

Email(Required)

Team Member 3

Name(Required)

First Last

Position Title(Required)

Phone(Required)

Email(Required)

Team Member 4

Name(Required)

First Last

Position Title(Required)

Phone(Required)

Email(Required)

Team Member 5

Name(Required)

First Last

Position Title(Required)

Phone(Required)

Email(Required)

Program/project sponsor

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

Within the Community QI Collective, a sponsor refers to someone who will assist reducing barriers to implementation within your organization or group. 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 project/focus area you plan to work on within the Community QI Collective.(Required)

How does your project/focus area impact the well-being of older adults?(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 implement change

How to set up a QI project

How to engage community voice

Utilizing data to tell a story

Utilizing data to understand when a change was successful

Planning for scaling improvement

Leading QI projects

QI tools to analyze data

What do you hope to gain from the Community QI Collective (e.g., specific knowledge, tools, etc.)?(Required)

How would this program benefit your organization?(Required)

Setting up for success

The next questions help to ensure we provide all the necessary support so you can be the most successful in this program.

What type of support do you anticipate needing to successfully complete this program?(Required)

Please indicate which of the following you are comfortable using:(Required)

Zoom

WebEx

Excel

Microsoft Office

Moodle

Mural

None

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 Community QI Collective web page, social media posts, and other promotional materials.

I agree

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Community QI Collective Cohort 5 Application

Community Quality Improvement Collective Application

Organization Details

Team Details

Program/project sponsor

Project details

Familiarity with quality improvement

Setting up for success

Current Work

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