Perioperative harm programme: teamwork and communication
intervention roll-out

Expression of interest registration form

Please read the Perioperative harm programme: teamwork and communicationintervention roll-out - request for expressions of interest before completing this form.

Please send the completed and signed form to Emma Forbes by 5pm 28 April 2015.

DHB:
Hospitals involved:
Number of theatres:
Preferred Cohort (one, two or three)
Primary objective: please provide a statement of your reasons for expressing an interest to be part of the cohort you’ve indicated for this initiative
Level of involvement in similar initiatives:
Eg, please specify whether or not you’re already doing any of the interventions (briefing, paperless checklist, debriefing) and to what level (i.e. number of theatres / specialities)
Eg, please specify to what extent (if any) your organisation has rolled out the Teamwork and Communication module from The Productive Operating Theatre, sponsored by the Ministry of Health?
Any other useful information:
Team Member Contact Details
It is anticipated local teams may vary in size and make-up and may include clinicians, quality improvement staff and managers. Please provide contact details for team members who will be involved in learning sessions and webinars. We appreciate it’s early in the process to specify names for these roles; the list can be changed or modified prior to the start of the project if necessary.At a minimum, specify the Project Manager for this role, so we know who to engage with about this expression of interest.
Clinical Lead / The Clinical Lead should be a senior clinician based in the surgical theatre
Name
Title
Phone
Email
Project Manager / The Project Manager will be the key contact with the Commission and will provide overarching coordination at your site. It is important that this person is from within the theatre environment.
Name
Title
Phone
Email
Quality Staff Member / It is expected that the project team will be able to draw on a member of the organisation’s Quality and Risk staff for support
Name
Title
Phone
Email
Executive Sponsor / It is expected the Executive Sponsor will take ownership at a senior executive level to facilitate change and improvement across the organisation’s surgical theatres
Name
Title
Phone
Email

Endorsement and authorisation (to be signed by the Director of Surgical Services or equivalent position)

I confirm that:

  • There is senior management and clinician support for participation, including any evaluation process, in the perioperative harm programme: teamwork and communication intervention roll-out;
  • The DHB commits to participating in the roll-out and providing necessary data for the Quality and Safety Marker (once confirmed following DHB consultation)
  • A project manager is nominated to liaise with the Reducing Perioperative Harm team at the Commission.

I endorse this DHB, ______to participate in the perioperative harm programme: teamwork and communication intervention roll-out.

Signature: / Date:
Name:
Title:

Completed expressions ofinterest must be submitted to the Emma Forbes () at the Commission by 5pm 28 April 2015.

Enquiries

For further information, please contact:

Emma Forbes, Senior Project Manager

04 901 6055

The Commission, at its discretion, may discontinue this call for expression of interest; decline to accept any application; or, modify the number of participants in order to satisfy requirements and achieve overall programme objectives.

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