March of Dimes, California Chapter by G2iv1V


  March of Dimes Hospital QI Initiative: Elimination of Non-Medically Indicated Deliveries
                            Before 39 Weeks Gestational Age
                                                  APPLICATION FORM
    Please complete all sections below and submit by April 15, 2012 to the March of Dimes at
                              This information will not be distributed outside of March of Dimes.
 Name of Hospital:
 Hospital System (if applicable):
 Name of Project Coordinator*:                                                   Title:
 Telephone:                                          Email:
 Mailing Address:
                                                Team Contact Information
 * Project Coordinator may be one of the champions/staff leads identified in the team contact section or may be an additional
 team member. This person should be designated with the role of ultimate project oversight and management to ensure
 implementation objectives and timelines are met.
       Please provide contact information for staff champions and leads in all four sections below and
                       obtain signatures of commitment from all four team members.
 Physician Champion Name:                             QI/Data Lead Name:

 Phone:                                                       Phone:
 Email:                                                       Email:
 Signature: ____________________________                      Signature:________________________________
 Nurse Champion Name:                                         Delivery Scheduling Lead Name:

 Phone:                                                       Phone:
 Email:                                                       Email:

 Signature: ____________________________                      Signature:________________________________
                                                  Baseline Hospital Data
                                                            What is the source for the baseline data?
 Total Deliveries Per Year:
 Current rate of elective deliveries <39 weeks:               What is the timeframe for the baseline data?
 Current rate of c-sections <39 weeks:
 Current rate of inductions <39 weeks:               Is there a hospital policy in place to eliminate elective
                                                     deliveries before 39 weeks?
 Does your hospital currently have a Quality Improvement team in place?
 If yes, what QI initiatives has the team conducted?

 Is your hospital currently participating in a perinatal Quality Improvement collaborative or task force?
 If yes, which perinatal measures are you tracking?

                                     Quality Improvement Service Package (QISP)
 As part of the quality improvement process of eliminating elective deliveries before 39 weeks gestational
 age, our hospital will utilize all components of the March of Dimes 39+ Weeks Quality Improvement Service
 Package: (circle one)              YES         NO

           Grand Rounds                            “Experts in the field” (blog/live chats)
           Webinars                                Secure web-based data portal
           Educational materials (available for purchase)

Project Coordinator Signature: _________________________Date:__________________

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