Background Quality Improvement Team Information Form
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|
|<Insert Unit Type> Nurse Manager|
|<Insert Unit Type> Nurses on team (list all)|
|<Insert Unit Type> Physicians on team (list all)|
|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 originally created December 2012