Background Quality Improvement Team Information Form

CUSP Toolkit
Health care provider roles

Who should use this tool? Health care providers.

Please indicate people designated as <Insert Unit Type> Quality Improvement Team Members. Your team may not have people who serve in all of these roles.

These individuals from <Insert Unit Type> are members of the Quality Improvement Team.

Name & Title Role Phone & Email Address
  Content Specialist (e.g., Infectious Disease Physician, Intensive Care Physician)  
  <Insert Unit Type> Director  
  Hospital Patient Safety Officer or Chief Quality Officer  
  Nurse Champion  
  Nurse Educator  
  <Insert Unit Type> Nurse Manager  
  <Insert Unit Type> Nurses on team (list all)  
  <Insert Unit Type> Physicians on team (list all)  
  Respiratory Therapist  
  Senior Executive (Vice President or above)  
  Social Work, Support Staff (e.g., Technicians, Ward Clerks, Nurse's Aides)  
  Staff from Safety, Quality, or Risk Management Office  
  Unit Champion (Unit Team Lead)  
  Other Roles? (fill In below)  

We recommend redesigning this roster to meet the needs of your team and posting it in a prominent area.

Page last reviewed December 2012
Internet Citation: Background Quality Improvement Team Information Form. December 2012. Agency for Healthcare Research and Quality, Rockville, MD.