NC Prevent CAUTI Collaborative Registration

Default Section

Please submit the following information to register your hospital for the NC Prevent CAUTI Collaborative. Information on next steps will be sent to you upon receipt of your registration form and signed DUA.

*
Step 1: Please choose your hospital from the following list.

Step 1: Please choose your hospital from the following list.

*
Step 2: Please provide contact information for the person who will serve as the primary contact for this initiative. If this role yet to be identified at your hospital, please provide the person who will at least get the process started and manage communication with the NC Quality Center.

Step 2: Please provide contact information for the person who will serve as the primary contact for this initiative. If this role yet to be identified at your hospital, please provide the person who will at least get the process started and manage communication with the NC Quality Center. Last Name:
First Name:
Title:
Email Address:
Phone Number:
Fax:

Step 3: Please click on the link below to download the collaborative Data Use Agreement (DUA) and NCSHIM Hospital Participation Agreement. Both documents needs to be signed by your CEO and returned to the NC Quality Center using instructions listed at the bottom of each agreement.
The NC System for Infections Measurement (NCSHIM) is the NC Quality Center's secure, online database of infection measures and will be used to store CAUTI measure data.

Hospital-level and aggregate collaborative unit data may be included in confidential quarterly feedback, reports and presentations to NC collaborative hospital participants in accordance with all applicable federal or state medical/peer review, confidentiality and data privacy and security requirements applicable to Hospital and NC Quality Center and under the terms and conditions of the NC Center for Hospital Quality and Patient Safety Confidentiality Agreement.
By signing this document, your hospital agrees to keep confidential any reports or comparative data provided by the NC Quality Center or collaborative partners that include performance rates on another NC hospital.
Click Here to Download the DUA and NCSHIM Hospital Participation Agreement

Questions/Comments?

Questions/Comments?

NC Prevent CAUTI Collaborative Registration

Default Section

*Step 1: Please choose your hospital from the following list.

*Step 2: Please provide contact information for the person who will serve as the primary contact for this initiative. If this role yet to be identified at your hospital, please provide the person who will at least get the process started and manage communication with the NC Quality Center.

Questions/Comments?

*
Step 1: Please choose your hospital from the following list.

*
Step 2: Please provide contact information for the person who will serve as the primary contact for this initiative. If this role yet to be identified at your hospital, please provide the person who will at least get the process started and manage communication with the NC Quality Center.