Enrollment Form: Quality Circle including iNICQ for Critical Transitions

Center-level enrollment in Quality Circle includes iNICQ for Critical Transitions and other programs and resources, and includes automatic annual renewal. Please complete this form to enroll your center. Invoices will be sent separately.

Question Title

* 1. Are you enrolling a current VON member center? (See a list of VON members)

My center is a VON member AND participated in iNICQ 2020 Improving Critical Transitions.

My center is a VON member BUT DID NOT participate in iNICQ 2020 Improving Critical Transitions.

My center is not a VON member.

Question Title

* 2. What features of the Quality Circle are your team planning to utilize?
(Select all that apply)

iNICQ Critical Transitions

VON Quality Improvement (QI) Foundations

Responding to Neonatal Abstinence Syndrome (NAS) education

Antibiotic Stewardship education

QI Library

Question Title

* 3. If you plan to participate in iNICQ, please indicate the transitions you intend to focus your improvement project on.

Transitions IN (example: Pre-admission In/Outborn + Golden Hours)

Transitions DURING (example: Acute + Growing Stronger)

Transitions OUT (example: to Home or Transfer + Follow Up & Through)

HANDOFFS

Have not yet determined

Question Title

* 4. If you plan to participate in iNICQ, please describe the focus or area of improvement you will work on during the collaborative.

Question Title

* 5. Center Enrollment Information

Name *

Center Name *

City/Town *

State/Province

Country *

Email Address *

Phone Number

Question Title

* 6. Even though payment will be due later, your center will be invoiced for Quality Circle membership for 2021. Fees are $7,500 (prorated quarterly) in addition to Core Membership fees.

I acknowledge my center will be invoiced for Quality Circle membership for 2021.

Question Title

* 7. Please indicate the information that influenced your decision to enroll your center in the Quality Circle (select all that apply):

Previous experience in a VON collaborative (iNICQ/NICQ)

QI Grand Rounds

Information about iNICQ: Improving Critical Transitions

Information about educational courses ("Responding to NAS")

Sample lesson from "Responding to NAS"

Attendance at an Annual Quality Congress

Consultation with VON staff

Improvement stories/testimonials from participating teams

Other (please specify)

Enrollment Form: Quality Circle including iNICQ for Critical Transitions

Question Title

* 1. Are you enrolling a current VON member center? (See a list of VON members)

Question Title

* 2. What features of the Quality Circle are your team planning to utilize?(Select all that apply)

Question Title

* 3. If you plan to participate in iNICQ, please indicate the transitions you intend to focus your improvement project on.

Question Title

* 4. If you plan to participate in iNICQ, please describe the focus or area of improvement you will work on during the collaborative.

Question Title

* 5. Center Enrollment Information

Question Title

* 6. Even though payment will be due later, your center will be invoiced for Quality Circle membership for 2021. Fees are $7,500 (prorated quarterly) in addition to Core Membership fees.

Question Title

* 7. Please indicate the information that influenced your decision to enroll your center in the Quality Circle (select all that apply):

* 2. What features of the Quality Circle are your team planning to utilize?
(Select all that apply)