Guide for Developing a Community-Based Patient Safety Advisory Council

Appendix B. Council Information Sheet and Application

A sample of the member information sheet and application for patients or caregivers for the Aurora Health Care Patient Safety Partnership Council follows. With minor edits, the information and application can be adapted for use by most patient advisory councils.

Information Sheet

What is the Patient Safety Partnership Council?

The Patient Safety Partnership Council is a group of committed patients, caregivers, health care providers, and community members who work together to improve medication safety for individuals 55 years and older.

What are the criteria for being council members?

  • Must be 55 years or older.
  • Able to attend meetings every other month (date, time, and location to be determined).
  • Must maintain appropriate and confidential handling of personal information.
  • Able to listen to differing opinions and share different points of view.
  • Be positive and supportive of the project's mission.
  • Comfortable speaking candidly in a group.
  • Able to use experience constructively.
  • Able to work productively and collaboratively with council members whose background, experience, and style may be different than their own.
  • Able to reflect on issues and priorities that are different than their own.

What are the responsibilities of council members?

  • Be accountable to those whom they represent.
  • Reach out broadly and listen to other patients, families, health care providers, and community members.
  • Be committed to improve care for all patients and family members.
  • Maintain confidentiality at the council meetings and outside the meetings.
  • Respect the collaborative process and the council as the forum to discuss issues.
  • Be willing to listen to differing views.
  • Encourage all council members to share ideas and viewpoints.

What is the time commitment for council members?

Council members make a 2-year commitment. The council will meet every other month at a date, time and location to be determined by the members. Council members may be asked to participate in activities, such as educational workshops and community outreach.

What kind of support will the council members receive?

  • Education and training at a 1½-day orientation retreat. Council members are invited to an orientation retreat. The retreat's objective is to establish a forum and a process for health care consumers and patients to partner with other health care stakeholders and, through this partnership, take on bold, creative initiatives that continuously make health care better. At the retreat, the vision, mission, and objectives of the council will be established. Patient and caregiver council members will receive one night's complimentary lodging at the conference center for the retreat. Three meals will be provided during the retreat.
  • Stipend for attending council meetings. Members of the patient advisory council will receive a $100 stipend for each council meeting attended.
  • Recognition. With permission, the members of the patient advisory council will be recognized through Aurora Health Care internal communications and in media and professional communications.


Date: ________________

Name: __________________________________________________________________________________
Mailing Address ___________________________________________________________________________

Street: ___________________________________________________________________________________

City: __________________________________   State: ________   ZIP Code: ________________
Home Telephone: ________________________    E-mail Address: ______________________________

1. What is your preferred way of receiving communication about the council?
   ___ E-mail ___ Regular Mail

2. Is it okay to share your contact information (address, telephone number, and E-mail address) with other members of the council?
   ___ Yes ___ No

3. Have you received care at a clinic or hospital for which this council is being formed?
   ___ Yes ___ No
   3a. If Yes, at which clinic or hospital did you receive care? ____________________________________

4. Do you have any dietary needs we should be aware of (i.e. vegetarian)?
   ___ Yes ___ No
   If Yes, please elaborate. ____________________________________________

5. Do you have any special needs we should be aware of?
   ___ Yes ___ No
   If Yes, please elaborate. ____________________________________________

6. Why would you like to be on the council?

7. What issues would you like to see the council address?

8. What special interest or experiences would you like to offer to the council?

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Page last reviewed April 2018
Page originally created December 2012
Internet Citation: Guide for Developing a Community-Based Patient Safety Advisory Council. Content last reviewed April 2018. Agency for Healthcare Research and Quality, Rockville, MD.
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