5-Diamond Patient Safety Program Project Reporting Form Please complete this reporting form and submit it to the Network 11 office upon completion of each module. Upon verification and review of your outcomes, the Network will designate the appropriate Diamond status. We will contact you to let you know of your achievement. Meanwhile, you may begin your next module, choosing any of the remaining modules, in any order. We encourage you to submit your outcomes upon completion of each individual activity. If you have any questions, have changes regarding your information or modules of interest, or need additional resources, please contact Network 11 by email at firstname.lastname@example.org or by phone at 651-644-9877. Participant Information FACILITY NAME: PROVIDER #: NPI #: PROJECT CONTACT: JOB TITLE: EMAIL: PHONE: # OF STAFF AT FACILITY # OF STAFF THAT PARTICIPATED IN MODULE (100% STAFF PARTICIPATION REQUIRED) Module Completed PATIENT SAFETY PRINCIPLES* INFLUENZA VACCINATION COMMUNICATION MEDICATION RECONCILIATION CONSTANT SITE CANNULATION MISSED TREATMENTS DECREASING DIALYSIS PATIENT- PATIENT SELF-MANAGED CARE PROVIDER CONFLICT SHARPS SAFETY EMERGENCY PREPAREDNESS STENOSIS MONITORING HAND HYGIENE SLIPS, TRIPS, & FALLS HEALTH LITERACY TRANSPLANTATION *Must Complete First 1. Please mark if the following required elements were completed for this module and comment how the facility completed each of the elements: Transplantation inservice completed. Yes No Staff complete the pre and post tests. Yes No Use tracking tool to ensure new patients receive transplantation education. Yes No Use tracking tool to ensure monthly labs are submitted for patients on waitlist. Yes No Submit the name of the staff to be the transplant liaison for the facility. Yes No 2. Please mark if the following required measures were met and comment on the process the facility used to meet the measures: 100% of staff inserviced on transplantation as a group. Yes No 100% of staff complete the pre and post tests. Yes No Submit completed transplant education tracking tool. Yes No Submit completed monthly lab sample tracking tool. Yes No Identify facility-level Transplant Liaison. Yes No 3. Other than the required elements listed above, what additional activities were completed? 4. Describe outcomes and/or changes in policies, practices, and/or procedures resulting from this module. 5. Provide recommendations for improving this module. 6. Please submit the following required documentation to Network 11: Completed project reporting form (page 1 and 2). Inservice attendance log (inservice needs to be completed as a group). Transplantation Pre and Post tests. Completed transplant education tracking tool. Completed monthly lab sample tracking tool. Name of facility-level transplant liaison. SIGNATURE OF PROJECT CONTACT: __________________________________________ DATE: __________________________________________ Submit this form and all required documentation to: Renal Network 11, 1360 Energy Park Drive, Suite 200, St. Paul, MN 55108 FAX: 651.644.9853 Please do not submit modules via email.
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