REGISTRATION CONFIRMATION by QJ2kKR

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									                                 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 5diamondsafety@nw11.esrd.net 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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