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Please complete the application below to participate in the 5-Diamond Patient Safety Program. Once your application has been processed you will receive a confirmation email with further information.
Applicant Information Facility Name: Medicare Provider #: Facility NPI # : Name of Project Contact Person (at your facility): Job Title : Email: Phone: # of staff in your facility: (Please note modules require 80 - 100% participation of staff) # of patients in your facility::
Applicant Information
Facility Name:
Medicare Provider #:
Facility NPI # :
Name of Project Contact Person (at your facility):
Job Title :
Email:
Phone:
# of staff in your facility: (Please note modules require 80 - 100% participation of staff)
Please indicate below the modules your facility is interested in completing: Patient Safety Principles * (Mandatory module for all participants) Decreasing Dialysis Patient & Provider Conflict (DPC) Emergency Preparedness Flu Vaccination Hand Hygiene Health Literacy **NEW** Medication Reconciliation Missed Treatments Patient Self-Managed Care **NEW** Sharps Safety Slips, Trips, & Falls Stenosis Surveillance **NEW** Other (please indicate: )
Please indicate below the modules your facility is interested in completing:
Patient Safety Principles * (Mandatory module for all participants) Decreasing Dialysis Patient & Provider Conflict (DPC) Emergency Preparedness Flu Vaccination Hand Hygiene Health Literacy **NEW** Medication Reconciliation Missed Treatments Patient Self-Managed Care **NEW** Sharps Safety Slips, Trips, & Falls Stenosis Surveillance **NEW** Other (please indicate: )
If you have any questions or need assistance, please contact Heather Cecil, at hcecil@nw5.esrd.net or by fax at 804.794.3793.
Thank you for your dedication to patient safety issues within the dialysis community.
