GRANT PROJECT: Get with the Guidelines- Stroke (GWTG) Mini- Grant Application ______
ILLINOIS CRITICAL ACCESS HOSPITAL NETWORK
Grant Agreement
The Illinois Critical Access Hospital Network (ICAHN), 245 Backbone Road East, Princeton, Illinois 61356 and the following hospital agree to a grant of $400 from ICAHN toward the cost of Get with the Guidelines Stroke Tool
Hospital Name:______
Hospital Address:______
City/State/Zip: ______
Stroke Director:______
The Grantee will receive a one year grant of $400.00 from ICAHN and agrees to the following:
□ Upon approval, the Grantee will a completed application to Quintiles/Outcome along with the required PHA allowing de-identified aggregate data from the hospital to be included in the ICAHN benchmark for use by ICAHN in research, education, and quality improvement. (Once an application is submitted, Quintiles will then invoice the hospital for the appropriate payment due.
□ No later than March 30, 2016 the grantee will contact Quintiles/Outcome to set up free training for two hospital employees on how to use the GWTG tool.
□ Not later than March 30, 2016, Grantee will enter 15-30 retrospective stroke patient charts as a means of establishing a baseline performance.
□ Not later than March 30, 2016, Grantee will begin live data entry into the GWTG registry for all stroke patients treated by or transferred from the grantee’s Critical Access Hospital.
A. Additionally, the grantee agrees to continue to remain a designated Acute Stroke Hospital for the duration of this contract.
B. Grantee agrees to complete 4 community education outreach opportunities specific to stroke per year in partnership with other community organizations using
community awareness and educational materials offered free by ICAHN if desired.
ICAHN Agrees to provide:
□ A one- time grant of $400 to the participating hospital.
□ Provide at least 2 accredited continuing education webinars each year to meet the requirement by the state for stroke center designation.
□ Provide regularly scheduled newsletters to the grantee’s stroke director events.
□ Recognize each participating hospital with a GWTG Participation Award once the hospital completed its retrospective entry.
□ Provide stroke coordination and support in collaboration with the American Heart/American Stroke Association and ICAHN’s appointed coordinator.
Term: The period of this grant agreement is available for Jan 1 2016 through Dec 2016
The parties understand and agree that the attached Basic Grant Terms.
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Grantee: Grantor: Illinois Critical Access Hospital
Network
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Grantee Signature Patricia Schou, Executive Director
______
Date Execution Date
Send the grant application to Peggy Jones
Fax- 309-585-o172
Mail to Peggy Jones, 7 Stark Circle, Bloomington, IL 61704
Phone:309-663-0092
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