PA PQC Hospital Registration

Directions: To formally join the PA PQC, please complete this survey to identify the core team from your health system or birth center that will participate in the PA PQC. The team roster identified in this survey will:

(1) Participate in quarterly, in-person Learning Collaborative sessions;

(2) Launch quality improvement cycles in-between the Learning Collaborative sessions;

(3) Attend virtual sessions to support their quality improvement projects;

(4) Provide their data and report the information through Life QI.

(5) Complete surveys to show the progress of the initiative.

Question Title

* 1. Please name the health system that is joining the PA PQC.

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* 2. Please list the names of the birth hospitals/centers, NICUs, or perinatal clinics that will participate in the PA PQC.

Hospital, NICU, Center, or Clinic

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* 3. Please provide contact information for the Provider Champion for your PA PQC's Women's Health Team (e.g., a physician, nurse, or midwife champion who will help lead the maternal mortality and OUD-related quality improvement projects).

First Name

Last Name

Credentials

Title

Organization

Question Title

* 4. Please provide contact information for the Neonatal or Pediatric Provider Champion for your PA PQC Neonatal/Pediatric Team (e.g., a physician or nurse champion who will help lead the quality improvement projects related to improving care for opioid-exposed newborns in your health system).

First Name

Last Name

Credentials

Title

Organization

Question Title

* 5. Please provide contact information for the Administrative Champion for your PA PQC Team who will provide project management assistance.

First Name

Last Name

Credentials

Title

Organization

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* 6. Please provide contact information for the Data Collection and Reporting Lead for your PA PQC team who will lead the work to internally collect data for your team's quality improvement projects and report aggregate information through an online portal. (This person would also assist with the VON Day Audit if your health system elects to participate in the VON Day Audit.)

First Name

Last Name

Credentials

Title

Organization

Question Title

* 7. Please list the other members of your Multi-Disciplinary Team for Quality Improvement and Learning Activities. These teams can be identified at the facility-level. For each team member, please enter their information using the following syntax: first name, last name, credentials, title, primary facilities where the team member works, and email. (The champions listed above and the additional team members listed below will be invited to participate in all the PA PQC's activities and resources that were mentioned in this survey's directions.)

First Name, Last Name, Credentials, Title, Primary Facilities, Email

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* 8. Do any of your champions or multi-disciplinary team members have experience with quality improvement and patient safety principles, methods, and tools?

Yes

If yes, please name the people on the team who have quality improvement and patient safety experience.

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* 9. Please suggest community-based organizations outside of your health system that you would like us to invite to join the PA PQC to help your health system and facilities lower maternal mortality and improve perinatal care for OUD and NAS.

Community-Based Organization and Contact Information: