* 1. Participation Agreement
Before you apply, be sure you can commit to the following:

1) Participants commit to participating in an open learning network to develop and share best practices, problems and solutions. This will include having at least one active representative participate in once a month conference calls to share program models in some detail together, discuss successes, and jointly brainstorm solutions to problems. 

(2) Participants will send at least one representative to the 2019  SCCM Annual Congress to participate in a panel discussion on establishing Post ICU Clinics.

(3) Participants agree to participate in some form of quality improvement data collection and share within collaborative.

(5) Participants will submit an end-of-year report.

(6) Our Hospital Administrative leadership (CEO or other and CNO) and our ICU Leadership have read the document and understand all of the requirements to participate in this support network. We understand that administrative sponsors must commit to supporting the staff during this quality improvement program with the resources necessary to be successful

* 2. What is your full name and credentials?

* 3. Institution name and address

* 4. Email address

* 5. Phone number

* 8. Enter health system, if applicable

* 9. Does your hospital currently offer a post ICU clinic for patients after discharge?

* 11. Describe the institutional context and specific local leadership team who would organize and run the clinic.

* 12. Describe your plan to implement a clinic this year or if already running, plan to make improvements.

* 13. Describe how participation in the Thrive Post ICU Clinic Collaborative will help you succeed with the question above.

* 14. Is there any additional information you would to share with the reviewers?

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