Project Team Acknowledgement Form

advertisement
Vascular Access Long Term Catheter Reduction Collaborative
2015
Project Team Acknowledgement/Accountability
To acknowledge that each team member below is aware of The 2015 Vascular Access Collaborative
Project, please print/type name and then have team member initial. Return this document to The Renal
Network to the attention of Cindy Miller at [email protected] or fax to 317-257-8291
By February 28, 2015
Facility Name_________________________CCN__________________________________________
Medical Director:
Initial:
Administrator:
Initial:
Nurse Manager:
Initial:
Vascular Access Manager:
Initial:
Modality Educator:
Initial:
Patient Representative:
Initial:
Facility Social Worker:
Initial:
Other:
Initial:
Medical Director Accountability
The Centers for Medicare Services (CMS) is committed to improving vascular access outcomes and has
included this outcome in your facility Quality Assessment Performance Improvement (QAPI).
Please sign below to acknowledge that you accept your role of leader in this improvement project.
Medical Director Signature______________________________________
Email Address_______________________________________
Download