NW2 2019 Home Therapies Quality Improvement Activity (QIA)
Key Facility Staff

QIA Key Staff Contact Information Form

Please provide the name, phone number, and email address of the project lead, CROWNWeb LEAD and QAPI LEAD via the form below by December 31, 2018.

Instructions:

Populate all fields.
Key staff will be the primary contacts for this QIA: Project Lead will be the person responsible for launching interventions and reporting.
CROWNWeb Lead is the person responsible for entering/reviewing facility data (QIA measures and re-measures are based on CROWNWeb data)
QAPI Lead is the person who coordinates and leads monthly facility QAPI meetings. (Where QIA goals and measures are reported and discussed)
Completion is dependent on all fields being completed.

Question Title

* 1. Please select your facility from the dropdown list below; facility name, CMS Certification Number (CCN - 33-XXXX), and city/town have been included.

Question Title

* 2. Home Therapies QIA Facility Lead

Home Therapies QIA Lead Name

Home Therapies QIA Lead Title

Home Therapies QIA Lead e-mail

Home Therapies QIA Lead Phone Number

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* 3. QAPI Lead

QAPI Lead Name

QAPI Lead Title

QAPI Lead e-mail

Question Title

* 4. CROWNWeb Lead

CROWNWeb Lead Name

CROWNWeb Lead Title

CROWNWeb Lead e-mail

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* 5. Is there anyone that you would like copied on reports/correspondence about the Home Therapies' QIA? If yes, please list names and e-mail address below:

Question Title

* 6. Comments or Questions about this QIA?

Thank you for completing the Home Therapy QIA Key Facility Staff Contact Collection for your facility.

We appreciate your time and effort.

Please click on "DONE" to submit your responses to the Network

Quality Improvement Team

IPRO ESRD Network of New York

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100% of survey complete.