QIPMO Nursing Facility Visit

Your consultation today was provided by the Quality Improvement Project for Missouri (QIPMO), which is funded by the MO Department of Health and Senior Services. Please take a few minutes and complete the following questions to help us improve our clinical and technical assistance to nursing facilities.

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* 1. Facility name

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* 2. Date of visit

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* 3. Job title/position

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* 4. Name(s) of QIPMO Nurse who visited your facility (check all that apply)

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* 5. Purpose of QIPMO visit (check all that apply)

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* 6. Was this the first time a QIPMO nurse(s) has visited your facility?

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* 7. During this visit, do you feel the information you received will help you improve care?

Very much Somewhat Not at all
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i We adjusted the number you entered based on the slider’s scale.

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* 8. Will you use the information from today's visit in your efforts to improve the quality of care?

Definitely Maybe Not at all
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i We adjusted the number you entered based on the slider’s scale.

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* 9. What would you describe as the most helpful aspect of this visit?

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* 10. Would you recommend this assistance to other facilities?

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* 11. Do you have any suggestions as to how we can improve our program?  Are there any other services you would like to see us offer?

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* 12. Were there any difficulties during this visit?  If so, what were they? (Please be as specific as possible.)

Informed Consent for QIPMO Program
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