Silver QI in Action - booking form

Full name (including title):

Work email: *

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)

Manager or sponsor name: *

Manager or sponsor email address: *

Project team members:

Please provide details of team members completing the course with you, including full name, email address, specialty and division. All team members attending the workshops will first need to have completed the Bronze.

Please give details of your QI initiative: *

What is the problem? 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?

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)

Do you have baseline data that evidences the problem? *

Yes
No

Will services other than your own be impacted by the project? *

Yes
No

Workshop dates:

please state which month's cohort you are interested in.

*

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Silver QI in Action - booking form