DQP Award Nominations
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Distinguished Quality Professional Award Nomination Form
The Missouri Association for Healthcare Quality (MoAHQ) established this award to recognize a professional in the field of quality management who has demonstrated significant accomplishments and contributions in the area of quality improvement, total quality management and/or continuous quality improvement.
Nominations are due by August 31, 2010.
For more information, please contact Sharon Burnett at the Missouri Hospital Association at 573/893-3700 or sburnett@mail.mhanet.com.
Nominee:
Nominee:
Business Address:
Business Address:
City, State, Zip:
City, State, Zip:
E-Mail Address:
E-Mail Address:
Work Phone:
Work Phone:
*
Nominator Information:
Nominator Information:
Nominated By:
Nominator's Phone Number:
Nominator's E-Mail Address:
Is the nominee a member of MoAHQ?
Is the nominee a member of MoAHQ?
Yes
No
Is the nominee involved in other professional organizations?
Is the nominee involved in other professional organizations?
Yes
No
If yes, list organizations.
If yes, list organizations.
MAHRM (Missouri Association for Healthcare Risk Managers)
MONL (Missouri Organization of Nurse Leaders)
NAHQ (National Association for Healthcare Quality)
Safety
ACHE (American College of Healthcare Executives)
Other
Is the nominee currently involved in quality management?
Is the nominee currently involved in quality management?
Yes
No
Does the nominee hold any certification in quality?
Does the nominee hold any certification in quality?
Yes
No
If yes, list certification:
If yes, list certification:
ISO 9000
CPHQ (Certified Professional in Healthcare Quality)
AMQUARP (American College of Medical Quality Utilization Assurance Review Professional)
ACHE (American College of Healthcare Executives)
CME (Certified Care Manager)
Other
Years of service in healthcare?
Years of service in healthcare?
Years of service in quality profession?
Years of service in quality profession?
Educational Background:
Educational Background:
High School
College - 2 year
College - 4 year
Graduate Degree
Trade/Vocational
Other
The nominee is directly involved in Quality Management through practice, teaching and administration or research. Areas involved:
The nominee is directly involved in Quality Management through practice, teaching and administration or research. Areas involved:
The nominee contributes actively in their role in supporting the mission of the organization and assists with development and implementation of the strategic plan. Examples of strategic planning involvement and mission support:
The nominee contributes actively in their role in supporting the mission of the organization and assists with development and implementation of the strategic plan. Examples of strategic planning involvement and mission support:
The nominee has demonstrated leadership within the practice setting (leadership can be the formal designated role as defined by position or can be defined by project responsibility). Example:
The nominee has demonstrated leadership within the practice setting (leadership can be the formal designated role as defined by position or can be defined by project responsibility). Example:
The nominee has demonstrated expertise in quality management through the application of an in-depth knowledge of quality management principles and practice. (Specifically list techniques utilized to apply quality principles with samples such as PDCA (Plan Do Check Act), NCQA (Natioanl Committee for Quality Assurance) Quality Template, QAPI (Quality Assessment Performance Improvement), project completion report, DMAIC (Define, Measure, Analyze, Improve, Control) (Six Sigma), and/or accreditation awards; Baldrige Award Application, JCAHO (Joint Commission on Accreditation for Healthcare Organization), URAC, AAHC (American Accreditation Healthcare Commission), NCQA (National Committee for Quality Assurance, Missouri Quality Award, etc.) Explain:
The nominee has demonstrated expertise in quality management through the application of an in-depth knowledge of quality management principles and practice. (Specifically list techniques utilized to apply quality principles with samples such as PDCA (Plan Do Check Act), NCQA (Natioanl Committee for Quality Assurance) Quality Template, QAPI (Quality Assessment Performance Improvement), project completion report, DMAIC (Define, Measure, Analyze, Improve, Control) (Six Sigma), and/or accreditation awards; Baldrige Award Application, JCAHO (Joint Commission on Accreditation for Healthcare Organization), URAC, AAHC (American Accreditation Healthcare Commission), NCQA (National Committee for Quality Assurance, Missouri Quality Award, etc.) Explain:
The nominee has made a distinguished contribution to quality management. Contributions are recognized on a local, state or national level. (Please list specific accomplishments or contributions that "distinguish" professional. Example: Specific project with timeframes and outcome of project, improvement to process and dollar impact noted or reduction in errors noted).
The nominee has made a distinguished contribution to quality management. Contributions are recognized on a local, state or national level. (Please list specific accomplishments or contributions that "distinguish" professional. Example: Specific project with timeframes and outcome of project, improvement to process and dollar impact noted or reduction in errors noted).
The nominee has communicated a positive image of quality management to the public. Explain:
The nominee has communicated a positive image of quality management to the public. Explain:
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