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* 2. Complete the below information.

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* 3. Please list the Primary and Secondary Contacts for this project. (If UNKNOWN, list the Facility Administrator for the Project Lead and Regional Corporate Representative as the Backup)

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* 4. Does your facility have a process in place to track and follow up on patient hospitalizations? 

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* 5. Do you have a Facility Patient Representative (FPR), Patient Subject Matter Expert (SME) or an actively engaged patient?

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* 6. If not, do you think there is a patient who may be interested in becoming a Facility Patient Representative (FPR) or Patient Subject Matter Expert (SME) for your facility?

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* 7. Do you think that your facility serves patients from a vulnerable population? If so, please select all that apply.

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* 8. Do you think that your facility serves patients with health disparities? If so, please select all that apply.

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* 9. Does your facility hold monthly patient engagement or educational activities for all patients?

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* 10. When is your facility's monthly QAPI meeting held?

Enter the date closest to typical meeting date.

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* 11. Was there a patient representative present at the QAPI meeting?

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* 12. Have you notified your regional corporate representative that your facility has been selected to participate in the 2019 Hospitalization QIA?

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* 13. Do you feel that you have or will have the resources and support necessary for your facility to successfully participate in the 2019 Hospitalization QIA?

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* 14. If you answered NO to Q14, what do you need (from the Network or from your organization) in order to be successful and able to participate fully in the 2019 Hospitalization QIA?

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* 15. What do you hope to gain by participating in this Quality Improvement Activity?

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