Thank you for your interest in implementing a quality improvement program to improve outcomes for VTE patients in your hospital. Please complete the questions below to help SHM become more familiar with your hospital and the reasons you have chosen to apply to the program. The deadline to complete the form for enrollment is September 18, 2019. 

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* 1. Hospital Name

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* 2. Contact Name and Title

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* 3. Contact Phone Number

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* 4. Contact Email Address

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* 5. Address of Hospital (including city, state and zip code)

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* 6. Please specify type of facility.

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* 7. Does your hospital have an Electronic Medical Record (EMR)? If so, please specify the vendor.

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* 8. Does your hospital have computerized physician order entry?

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* 9. Have you reviewed outcomes of current performance metrics related to the treatment of acute VTE at your institution to determine key priorities for improvement? If so, please describe.

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* 10. Please indicate the status of  improvement efforts at this site as it pertains to creating better outcomes for DVT and PE patients.

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* 11. If your hospital currently has a transitions of care program for VTE patients, please describe it including all intervention components.

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* 12. Which of the following areas related to transitions of care for VTE patients are you looking to improve within your institution? (Select all that apply).

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* 13. What are the specific objectives that you would like to achieve as a result of enrolling in a program to improve transitions of care for VTE patients in your hospital? Name at least two.

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* 14. Please select at least two processes that your team would prioritize in improving or implementing to improve transitions of care for VTE patients.

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* 15. Please describe the two units you plan to formally enroll in the FAST program at your institution.

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* 16. Please describe your hospital's relationship with any outpatient pharmacy providers.

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* 17. Are you able to identify any specific barriers or obstacles that your site may need assistance in addressing throughout the course of this project?

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* 18. Please describe your current institutional QI environment, highlighting areas of focus including availability of resources to support data collection and entry, support for new interventions, the experience of team members in conducting prior QI intervention projects.

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* 19. Are you now or have you been active in QI work, either within your hospital medicine group or at the hospital where the VTE transitions of care program improvement effort will be implemented? Please elaborate as to the scope of any previous work.

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* 20. Please describe your ability to implement a multidisciplinary team-based quality improvement initiative (including team members from nursing, pharmacy, hospital medicine and social work) that specifically addresses transitions of care for DVT/PE patients in your hospital.

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* 21. Have you identified an executive champion for the program? If so, please list the name.

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* 22. Please include the following information for your site lead.

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* 23. What are the strengths/skills that the site lead brings to this initiative? Please comment specifically on relevant experience in the areas of leadership, Quality Improvement, clinical focus, research and transitions of care improvement efforts.

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* 24. In the long term, what is your vision for the extent of eventual implementation of the SHM FAST program.

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* 25. Please add any additional comments or information you would like to share.

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