THROMBOSIS CANADA FACILITATED QUALITY IMPROVEMENT PROGRAM APPLICATION

Online Application

• PROJECT CHAMPION

• Title *

  Mr.   Mrs.   Ms.   Dr.

• Name *

• Title/Role *

• Organizaion *

• Mailing Address *

• City *

• Province *

  ...AlbertaBritish ColumbiaManitobaOntarioNew BrunswickNewfoundland and LabradorNova ScotiaPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesNunavutYukon

• Postal Code *

• Telephone  *

• Fax *

• E-mail *

• ORGANIZATION INFORMATION

• Please check your organization's formal structure *

  Family Health Team   Family Health Organization   Community Health Clinic/Centre   Other

• If other, please indicate

• Do you have a designated Quality Improvement Lead at your site? *

  Yes   No

• How many physicians are associated with your organization? *

• How many sites are within your organization? *

• Please comment on the distribution of your site(s) *

• Is your organization affiliated with a teaching institute? *

  Yes   No

• If yes, which one?

• What EMR Platform does your organization use? *

  PSS   Accuro   Oscar   Nightingale   Other

• If other, please specify

• ORGANIZATION'S EXPERIENCE

• Please comment on your organization's experience with Quality Improvement Programs. *

• What has been your greatest challenge when implementing Quality Improvement Initiatives? *

• ORGANIZATION'S COMMITMENT

• Please comment on how this program complements your organization’s strategic priorities. *

• Explain how you will ensure adequate time and resources are allotted to this program. *