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Pharmacists Application - I Raise the Rates Initiative to Increase Adult and Influenza Vaccination Coverage

ACP’s Center for Quality has received funding from the CDC, GSK and Merck to support our I Raise the Rates initiative. The program aims to increase adult and influenza vaccination coverage among older adults, adults with high-risk chronic conditions, and racial/ethnic minority adults by using quality improvement (QI) methodology. Please complete this application if you are interested in participating. Applicants will be considered on a first come, first served basis.
1.Full Name(Required.)
2.Credentials(Required.)
3.Email Address(Required.)
4.Pharmacy/Organization Name(Required.)
5.Pharmacy Address(Required.)
6.Number of pharmacists(Required.)
7.Number of pharmacy support staff(Required.)
8.How many pharmacists from your practice do you anticipate will participate in this program?(Required.)
9.Please describe your pharmacy setting/type (e.g., community-chain pharmacy, community-independent pharmacy, clinic-based pharmacy, grocery-store based pharmacy, hospital pharmacy, other.)(Required.)
10.Do you have support from your organization’s leadership to participate in ACP’s I Raise the Rates QI program?(Required.)
11.Do you have at least one pharmacist team member that can serve as project lead on behalf of your practice for this program?(Required.)
12.Do you currently administer flu and other adult vaccines in your practice?(Required.)
13.Which immunizations would you like to focus you QI project on?
14.Is your practice located in a rural, urban, or other medically underserved community?(Required.)
15.Is your practice able to provide the following data to ACP pre-/post-initiative?(Required.)
Yes
No
Immunization rates (de-identified, aggregated at the practice level)
Practice assessment survey (completed by one practice lead on behalf of practice)
Mini-z survey (completed by each participating clinician)
16.How many years have you been in practice?
17.Which of the following best describes your race/ethnicity?
18.Is there a local primary care practice that you would like to collaborate with on this program?
19.Please provide contact information of the local primary care practice you would like to collaborate with on this program (optional).
Current Progress,
0 of 19 answered