Silver QI in Action - booking form

Full name: *

Work email address: *

Contact no.: *

Job title: *

Staff group: *

Division: *

Specialty: *

If other, please specify:

Bronze Intro to QI - date attended/to attend: *

Please note that the Bronze is a mandatory prerequisite to the Silver.

Project team members joining you on the workshops: *

All team members will first need to have completed the Bronze.

Details of your QI initiative i.e. what is the problem that you're aiming to address? *

Who or what does it impact? Why is it important? You will be testing out changes during your project - how will you measure whether any changes have resulted in an improvement?

Do you have baseline data that evidences the problem? *

Please email your data to us upon submission of this form. If you do not yet have baseline data we will email you for further clarification about your project.

YES - I have baseline data

NO - I do not have baseline data and will need to speak to a member of your team.

What is the main improvement focus of the project? *

Patient safety

Health and safety

Clinical effectiveness

Patient experience

Staff experience

Customer experience

Sustainability (environmental)

Sustainability (financial)

Does this QI relate to a Datix incident, AER or Quality Summit?

if yes, please provide a reference number:

This QI will

increase efficiency

increase productivity

reduce costs

Sponsor or Manager email address: *

This application can only be processed once you have discussed your proposed project with your manager or sponsor; they will be contacted regarding your booking.

Do you have a Gold QI Coach in your division? If so, please enter their email address below.

If you are not sure, please discuss with your sponsor or line manager who can advise you.

Which cohort would you like to join:

*

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Silver QI in Action - booking form