National Improvement Challenge – Hypertension in Pregnancy

Application Form

Please complete the form below and submit along with project narrative via email to

Declaration of intent must be submitted no later than 11:59 p.m. ET on Friday, January 15, 2016.

Final applicationsmust be submitted no later than 11:59 p.m. ET onWednesday, June 15, 2016.

SECTION A – PROGRAM INFORMATION
Institution
Enter name of residency or educational program / Health System
Enter name of health system (if applicable)
Type of Program(s) – Select all that apply
☐Anesthesia ☐Clinical Nurse Specialist (CNS) ☐Doctor of Nursing Practice (DNP) ☐Family Medicine
☐Nurse Anesthetist (CRNA, DNAP) ☐Nurse Practitioner (NP) ☐Midwifery (CM, CNM)
☐OB/GYN or Osteopathic OB/GYN
Address
Enter street address
City
Enter city / State
Enter state / Zip
Enter zip
Primary Contact Email Address
Enter email / Primary Contact Phone Number
Enter phone
SECTION B – CONTACT INFORMATION
Please provide the educational faculty or residency program director overseeing the project.
Name
Enter name / Credentials
Enter credentials / Title
Enter organizational title
Email Address
Enter email address / Phone Number
Enter phone number
SECTION C – AUTHORIZED SIGNATURE
An authorized signatureis required from onehospital or health system administrator. Authorized individuals can include: hospital or health system CEO, quality and safety officer/administrator,department chair, residency program director, or other leadership designee identified by the applying institution.
Name of Signing Authority (please type or print) / Signature
Organizational Title
SECTION D – PROJECT NARRATIVE
The narrative should include a detailed description of the quality improvement projectand should follow the SQUIRE guidelines.
It must include the following:
  • Specific objective(s) related to severe hypertension in pregnancy; objectives may also address other causes of severe maternal morbidity
  • Stakeholders involved (list of all participating clinicians, patients, hospital administrators, and others who participated actively in the design or implementation of the project should be listed as an appendix)
  • Measurements (qualitative and/or quantitative)
  • Steps for implementation
  • Anticipated outcomes
The narrative should be single-spaced in 12-point Times New Roman font with 1-inch margins and should be no longer than 4 pages. Figures, charts, and pictures may be included separately as appendices but must be described or explained in the text submission (within 4 page limit). Any references should be submitted in APA format.
Institution name should appear on each page in the footer.
Please note: Approval by your institutional review board (IRB) may be required depending the project design and/or the methods of research proposed. IRB approval is dependent on your institution's policies, and is not a required component of this application. Please check with your institution regarding the need for IRB approval.

Updated 11/16/18