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 & TitleRolePhone & 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: CUSP Toolkit. December 2012. Agency for Healthcare Research and Quality, Rockville, MD.