Please provide updates and feedback by March 31, 2019.  

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* 1. Which QIA(s) are you reporting for?

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* 2. Please select your facility from the drop down list below; facility name, CMS Certification Number (CCN - 33-XXXX), and city/town have been included.

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* 3. Your name and contact information

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* 4. Your Feedback: Customer Focus

  Yes No N/A
Have the Network’s activities been helpful in supporting your work 
in the Transplant Quality Improvement Activity?

Have the Network’s activities been helpful in supporting your work 
in the Home Therapies Quality Improvement Activity?

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* 5. Your facility's current patient census:

Patient Engagement Activities

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* 6. Patient Knowledge Assessment Outcomes:

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* 7. How many patients and family members were educated on engaging in their care? (Hint: discussing treatment options could be considered engagement education)

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* 8. QIA Champion Recruitment:

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* 9. Does your facility have a policy to ensure patients/family members/care partners are involved in plan-of-care meetings?

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* 10. PDSA Review of the MEI Patient Interest Checklist

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* 11. Has your facility established / initiated patient and family support groups?

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* 12.  Did your facility hold a new patient adjustment group?

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* 13. Did your facility include a patient representative in any QAPI meetings (Jan - March)?

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* 14. Did your facility post outcomes from QAPI for patient review? (for example the # of patients interested in Transplant or Home Therapies?)

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* 15. Did your facility include a patient representative in a Governing Body or Regional Leadership meetings (Jan-March)?

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* 16. Have you identified any disparities to date related to patients not having access to Home Therapies?

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* 17. Have you identified any disparities to date related to patients not having access to Transplant?

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* 18. Staff Knowledge Assessment Outcomes:

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* 19. Education Station/Visual Display: What stage is your facility at?

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* 20. What INNOVATION would you like to share? (Examples:  Staff lunch and learn, Treatment options pop quiz competition in the waiting room, Patient Art Project, care partner support meeting)

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* 21. Comments or Questions about these QIAs?

Thank you for completing the March QIA MSR for your facility.
 We appreciate your time and effort.
 
 Please click on "DONE" to submit your responses to the Network
  
Quality Improvement Team
 IPRO ESRD Network of New York
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