QUALITY ACADEMY APPLICATION FORM
Applicant Information First Name:
Last Name:
Email:
Phone:
Facility/Site:
Department:
Current Role: Is Your Role Mostly Clinical or Non-Clinical: _______________________________
What Are Your Credentials:
Appointment Date at NYC Health + Hospitals:
Performance Improvement and Leadership Experience 1. Please rate your level of involvement with performance improvement projects to date. Take note that prior involvement in performance improvement projects is not required to apply . Very frequently* Frequently* Occasionally*
Rarely Never Other
*Note: If you answered “Very Frequently”, “Frequently”, or “Occasionally” above, please list your mentor on the project, or the individual who provided you with guidance and support in project design and/or implementation (list more than one individual if it applies):
2. Do you have experience in the following steps of performance improvement? Choose “Yes” or “No” next to each item. a. Identifying an issue with a process or outcome that needs improvement b. Defining the aim of a project and the evidence of the issue c. Assessing the current state or existing processes d. Planning and designing tests of change e. Engaging in small tests of change Yes No
f. Learning from the tests through data analysis g. Modifying the intervention and scaling up
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