Silver QI in Action - booking form

Details of your QI initiative i.e. what is the problem that you're trying to fix? *

Who or what does it impact? Why is it important? You will be testing out changes during your project - how will you measure whether any changes have resulted in an improvement?

Do you have baseline data that evidences the problem? *

YES - I have baseline data

Please email your data to us upon submission of this form. If you do not yet have baseline data please speak to a member of our team before proceeding to book on the programme.

Full name: *

Work email: *

Contact no.: *

Job title: *

Staff group: *

Division: *

Specialty: *

If other, please specify:

Bronze Intro to QI - date attended/to attend: *

(Please note that the Bronze is a mandatory prerequisite to the Silver)

Manager or sponsor email address: *

Project team members:

Please provide details of team members attending the workshops with you, including full name, email address, specialty and division. All team members attending the workshops will first need to have completed the Bronze.

What is the main improvement focus of the project? *

Patient safety
Health and safety
Clinical effectiveness
Patient experience
Staff experience
Customer experience
Sustainability (environmental)
Sustainability (financial)

Will services other than your own be impacted by the project? *

Yes
No

Workshop dates:

please state which month's cohort you are interested in.

*

Preparing for your visit with us: Before you arrive, during your stay and how we'll look after you

Find out more about our specialist children's services

Donate to our hospitals charity to support one of our appeals!

Need to cancel or change your appointment? Let us know ASAP.

Silver QI in Action - booking form