2021 National Quality Award Examiner Training Observation Pre-Registration Form

Registration is limited, first come first serve, and closes December 31, 2020. Please complete this form if you plan to register as an observer prior to paying. Once you complete this form, the link to payment and the learning platform will be in the thank you message.

More details on this program can be found at ahcancal.org/examiners

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* 1. First and Last Name

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* 2. Phone number

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* 3. Email address

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* 4. Please provide your full mailing address, as we will be mailing training materials and resources directly to you prior to the training.

Street

Street 2

City

State

Zip Code

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* 5. Areas of Expertise

Skilled Nursing

Assisted Living

ID/DD Services

Veteran's Services

Baldrige Criteria

Other Quality Improvement Criteria

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* 6. Have you ever written, or been involved with the writing of a Quality Award (or Baldrige) application?

Yes

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* 7. Please share your interest and reason for participating in this observation program.

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* 8. Please list all long-term care organizations with which you have a conflict of interest for this year. A conflict of interest is identified as previous long-term care employers and/or direct competitors (note that you will not be assigned to shadow an application from your state, so only list direct competitors in different states). If you work as a consultant, please make sure to list the member organizations with which you have a consulting relationship. If you have questions, please contact qualityaward@ahca.org.

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* 9. What is your time zone preference for team shadowing?

Eastern

Central

Mountain

Pacific

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* 10. What level do you prefer to observe? For more information on these levels, visit ahcancal.org/examiners

Senior

Master

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* 11. Conditions of Involvement
Please review and acknowledge.

As a Senior Examiner, Master Examiner, Observer or Judge for the AHCA/NCAL National Quality Award program, I commit to:
Abide by the Examiner Code of Ethical Standards
Honor Applicant Confidentiality:

Not disclose the identities of applicants to anyone at anytime

Not disclose any specific or confidential information gained from applications ()

Not share copies of applications or comments except as dictated by program processes

Not retain any copies of applications or comments after the review session

Not initiate personal contact with applications assigned to your team.

Honor the Confidentiality of the Review Process:

Not disclose any information gained from the review session, beyond descriptions of the evaluation process

Not discuss award decisions to any applicants (including within your own organization) until the official award notifications have been made by program staff

Not disclose the names of Examiners assigned to an application

Not disclose any discussions or comments by Examiners or Judges on applications

Not publicize any information regarding the review process unless approved in writing by program staff

Honor the confidentiality of AHCA/NCAL materials:

Not disclose any documents, materials or other information provided by AHCA/NCAL, either orally or in writing, as part of the Quality Award review process to any outside entities or any individuals not involved in the review process

Disclose Potential Conflicts of Interest, as follows:

Any applicant connected with your organization

Any applicant connected to an organization you have worked for in the past

Any applicant representing a direct local competitor of your organization

Any applicant or parent company for which you or your organization have served as a consultant for in the past or present

Personal knowledge of the applicant that may be perceived as influencing the fair examination of the application

Persons working in consultant roles may be required to submit a list of current and past long-term care clients.

Honor AHCA/NCAL Policies on Using the National Quality Award Program Logo

The National Quality Award program logo may only be used by AHCA/NCAL, AHCA/NCAL State Affiliate members promoting the program, or by applicants who include both the award level and year received.

Adhere to Established Evaluation Processes

Use only the current established evaluation processes as described during the current cycle’s training and manuals. This includes, but is not limited to, roles of team members, use of evaluation tools, scoring decisions and feedback formatting.

() Examiners, Observers and Judges should feel free to share key learnings or best practices from their participation in the Award process without revealing the identity of the applicant or the source of their knowledge.

I have read, understand and will abide by the Quality Award Examiner Conditions of Involvement, if selected as an Observer.

Full Name

Date