NW4 EPIC 2021
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Facility Information
CCN:
Reporting Month:
Contact Information
Contact First Name
Contact Last Name
Contact Email
Meeting Information
QAPI Meeting Date:
**The QAPI Meeting Date must be within the same month as the Reporting Month. Please correct before submitting.**
How many patients, family member or caregiver Subject Matter Experts (SMEs) participated in the selected QAPI meeting date?
What are your barriers to engaging patients/family member SMEs in your QAPI meeting:
(Select All That Apply By Clicking in Box)
Other Description
What is your plan for impacting those barriers:
(Select All That Apply By Clicking in Box)
Other Description
WARNING!
We understand that your team was not able to have a patient/family member representative join this month’s QAPI meeting. We will utilize the barriers and feedback you shared to develop additional interventions to help your team.
Your SME(s) participated in QAPI meeting via:
(Select All That Apply By Clicking in Box)
WARNING: DO NOT ENTER PHI / PII ON THIS FORM.
No PHI / PII in the following fields.
Examples of PHI include patient name or initials, birthdate, SSN, etc.
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SME QAPI Meeting Engagement
Select Topics Discussed During QAPI Meeting with SME(s):
(Select All That Apply By Clicking in Box)
Plan of Care
Do you have Action Items at this time based on SME’s feedback relating to Plan of Care?
Please select all Action Items that apply as a result of SME’s partnership:
(Select All That Apply By Clicking in Box)
If “Other” is selected above, please provide a description
Peer Mentoring
Do you have Action Items at this time based on SME’s feedback relating to Peer Mentoring?
Please select all Action Items that apply as a result of SME’s partnership:
(Select All That Apply By Clicking in Box)
If “Other” is selected above, please provide a description
Patient Depression Screening and Referral
Do you have Action Items at this time based on SME’s feedback relating to Patient Depression Screening and Referral?
Please select all Action Items that apply as a result of SME’s partnership:
(Select All That Apply By Clicking in Box)
If “Other” is selected above, please provide a description
Infection Rates in Skilled Nursing Facilities Dialyzing Patients (BSI NH)
Do you have Action Items at this time based on SME’s feedback relating to Infection Rates in Skilled Nursing Facilities Dialyzing Patients?
Please select all Action Items that apply as a result of SME’s partnership:
(Select All That Apply By Clicking in Box)
If “Other” is selected above, please provide a description
Home Dialysis & Telemedicine
Do you have Action Items at this time based on SME’s feedback relating to Improving Patients Plan of Care?
Please select all Action Items that apply as a result of SME’s partnership:
(Select All That Apply By Clicking in Box)
If “Other” is selected above, please provide a description
Transplant
Do you have Action Items at this time based on SME’s feedback relating to Transplant?
Please select all Action Items that apply as a result of SME’s partnership:
(Select All That Apply By Clicking in Box)
If “Other” is selected above, please provide a description
Immunization
Do you have Action Items at this time based on SME’s feedback relating to Immunization?
Please select all Action Items that apply as a result of SME’s partnership:
(Select All That Apply By Clicking in Box)
If “Other” is selected above, please provide a description
Hospital Admissions, Readmissions, and Emergency Visits
Do you have Action Items at this time based on SME’s feedback relating to Hospital Admissions, Readmissions, and Emergency Visits?
Please select all Action Items that apply as a result of SME’s partnership:
(Select All That Apply By Clicking in Box)
If “Other” is selected above, please provide a description
Nursing Home Dialysis Blood Transfusions
Do you have Action Items at this time based on SME’s feedback relating to Nursing Home Dialysis Blood Transfusions?
Please select all Action Items that apply as a result of SME’s partnership:
(Select All That Apply By Clicking in Box)
If “Other” is selected above, please provide a description
Other
Do you have additional Action Items at this time relating to other topics based on SME’s feedback/discussions?
Please describe the action items or interventions discussed with SME for topics other than the ones listed before:
Please continue with submission of the form.
Next Step: Verify and Submit
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at bottom of the form
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WARNING: DO NOT ENTER PHI / PII ON THIS FORM.