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Program Application

The 5-Diamond Patient Safety Program consists of 9 modules that you may choose to complete, on a variety of patient safety topics. For each module completed, each facility will be tiered as a 1-Diamond, 2-Diamond, 3-Diamond, 4-Diamond, or 5-Diamond facility. Participating facilities will receive recognition as follows:

1 - 4 Diamond Facilities ~
Facility accomplishment written in REMARCS newsletter
Facility recognized on the Network's website

5 Diamond ~
Facility accomplishment written in REMARCS newsletter
Facility recognized on the Network's website
Special Recognition at our next Annual Council Meeting
2 Free Passes to attend the next Annual Council Meeting
Letter of recognition from the Board Chair
Plaque to display in the facility

Please complete the application below and submit it to the Network Office. Upon receipt, we will review your application and planned activities and send you a packet of materials explaining how each activity should be conducted and measured. You must begin with the Patient Safety Principles module, which is mandatory for all participants. However, once you have completed that module, you may select additional modules in any order. We encourage you to submit your outcomes upon completion of each individual activity. If you have any questions please contact us at 804.794.3757.

Applicant Information
Facility:
Provider #:
NPI #:

 

Name of person in charge of this project:

Job Title:

 

 

Email:

Phone:

   
# of facility staff involved:
(Please note modules require 85-100% of facility staff participation)
   


Please indicate which program(s) your facility will be striving to complete:

Flu Vaccination

If you are interested in another clinical patient safety topic not listed above, please identify it in the box below, along with a brief description of how you would monitor and evaluate it's effectiveness. We will contact you and let you know if your plan is approved.

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1527 Huguenot Road
Midlothian, VA 23113
804.794.3757
marc@nw5.esrd.net

Toll Free Patient Number 866.651.6272 © 2004 ESRD Network 5 All Rights Reserved