Health Connect Hospital Candidate Application

Question Title

* 1. Contact Information

Name

Hospital

Email Address

Phone Number

Are the following statements true or false about you and your hospital?

Question Title

* 2. My hospital is independent and not facing closure or a merger with a larger system.

True

False

Comment

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* 3. I am open to change and new ideas.

True

False

Comment

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* 4. I am interested in how to get the best ROI in the shortest amount of time with the optimal use of resources.

True

False

Please describe:

Question Title

* 5. As CEO or Administrator, I have the support and trust of our board

True

False

Comments:

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* 6. I am actively trying to engage my community.

True

False

Please describe:

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* 7. I am uncertain about what else to do to mobilize my community leaders.

True

False

Comment

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* 8. I am willing to invest in something new.

True

False

Comments:

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* 9. I have nagging concerns including but not limited to: (Check all that apply)

Patient loyalty and out migration

Lack of community awareness about hospital's capabilities

Lack of community awareness about hospital's intentions

The economic reality of hospital survival

Significant lack of community leader engagement

Other (please specify)

Health Connect Hospital Candidate Application

Question Title

* 1. Contact Information

Question Title

* 2. My hospital is independent and not facing closure or a merger with a larger system.

Question Title

* 3. I am open to change and new ideas.

Question Title

* 4. I am interested in how to get the best ROI in the shortest amount of time with the optimal use of resources.

Question Title

* 5. As CEO or Administrator, I have the support and trust of our board

Question Title

* 6. I am actively trying to engage my community.

Question Title

* 7. I am uncertain about what else to do to mobilize my community leaders.

Question Title

* 8. I am willing to invest in something new.

Question Title

* 9. I have nagging concerns including but not limited to: (Check all that apply)

Question Title

* 10. Is there anything else you would like us to know about your interest in the Health Connect Program?