NW6 - 2019 Quality Improvement Activity (QIA) - Education Station/Lobby Day Intervention:
Picture Collection Tool

Please read the following instructions carefully.

As part of your involvement with a Network 6-QIA Project during 2019, you are required to offer a lobby education activity to your patients. This education may be lobby day, education station and/or bulletin board in the topics related to your project. You will have until September 5th to submit to the Network the picture of your lobby activity for all the projects your facility is involved with.

INSTRUCTIONS:

This tool can be completed at any time until June 14th, 2019 by 6pm
You may upload the following documents: PDF, PNG, JPG, JPEG, GIF, DOC, DOCX.
The maximum size of your document must be 16 MB.
The picture must NOT include patient's faces.
It will take you approximately 10 minutes to complete
Once you start, you must complete it in one sitting as it will NOT save answers halfway
Survey completion is dependent on all required fields indicated by an asterisk (*)
Hit "DONE" at the end of page two to complete, save and submit your answers.
How to know it went through? After the survey you should be directed to Network 6 website.

FACILITY INFORMATION

Question Title

Follow the example on how to pick your facility. You must enter "N/A" in the other two states you are not picking from for your information to save.

Question Title

* 1. GEORGIA: If your facility is located in Georgia, please select your facility from this dropdown menu; otherwise select "N/A"

Question Title

* 2. NORTH CAROLINA: If your facility is located in North Carolina, please select your facility from this dropdown menu; otherwise select "N/A"

Question Title

* 3. SOUTH CAROLINA: If your facility is located in South Carolina, please select your facility from this dropdown menu; otherwise select "N/A"

Question Title

* 4. Please enter your contact information below:

Full Name *

Discipline or Role

Email Address *

Question Title

* 5. Has the Project Lead or Back-up Lead changed since your last survey submission? (Please specify new contact information)

Yes

If yes, Please submit the FIRST and LAS NAME, PHONE, EMAIL and identify if the change is for the lead or back-up
e.g. John Smith- new lead
e.g. 919-463-4500
e.g. info@nw6.esrd.net

Question Title

* 6. What lobby education are you submitting a picture for?

Lobby Day

Bulletin Board

Education Station

Question Title

* 7. If you did an Education Station that was displayed at another facility involved in the same topic QIA project, you may type your facility 6-digit CMS Certification Number (CCN) and Name to receive credit for all QIA facilities.
NOTE: This is only valid for Education Stations that are transportable to another facility. Bulletin Boards and Lobby Day must be one per facility.

CCN/ Facility Name 2

CCN/ Facility Name 3

CCN/ Facility Name 4

Question Title

* 8. For which QIA Project you are submitting your picture(s) today? (If you are in multiple project, you may choose all of them. You will be able to submit up to 5 pictures)

Blood Stream Infection (BSI) QIA

Long Term Catheter (LTC) QIA

Home Dialysis QIA

Transplant QIA

Vocational Rehab QIA

Question Title

* 9. When did you provided this education for your patients? (If Education Station or Bulletin Board, indicate the date that was first displayed in your lobby)

Date / Time

Date

PICTURE UPLOAD

NOTE: You must submit at least one picture per lobby education, but you have up to 5 fields in case you want to submit multiple shots and/or are in multiple QIA projects. You may also submit one now and submit one at a later time for another project by completing this tool again.