QI Study Submission Agreement (Page 1 of 2)

QI Study Submission Agreement (Page 1 of 2)

AAAHC Institute for Quality Improvement

Bernard A. KershnerInnovations in Quality Improvement Award Program 2016-2017

Your Quality Improvement (QI) study with the 10 elements (AAAHC Handbook Chapter 5, Subchapter I, C) identified and this completed/signed agreement must be sent by e-mail, in acomputer-generated format (pdf or MS Word), to . The entry deadline is 12 noon (Central time), September 23, 2016. Entries received after that time will not be accepted.

The AAAHC Institute has appointed an Expert Panel to review all submissions.The criteria against which the Expert Panel will judge submissions are listed in A and B below.

A.The Expert Panel will review all submissions for overall clarity and conciseness of the description of and/or rationale for:

The quality issue addressed
Appropriateness of the performance goal
Data collected (performance measure[s])
Data collection methodology
Data analyses and conclusions
Comparison of initial performance versus performance goal
The development and implementation of corrective action, and, if necessary, additional corrective action
Re-measurement, and, if necessary, additional re-measurement
New current performance versus performance goal
Methods of communication of the study findings throughout the organization

B.The Expert Panel will also review all submissions for evidence of: innovative thinking, working as a team, and setting an example that can be used in other ambulatory health care settings/for other ambulatory health care issues.

In order to be in compliance with HIPAA, no patient identifiers are allowed on the application.

The representatives of the 6 selected studies that most closely reflect the criteria used by the Expert Panel will receive:

1)Honoraria of $500 (limit 1 per organization, 6 in total) after making poster presentations at the AAAHC Achieving Accreditation Meeting in Tampa, Florida, March 17-18, 2017;

2)Complimentary registration (limit 1 per organization, 6 in total) to the AAAHC Achieving Accreditation program, to be held March 17-18, 2017, at the Tampa Marriott WatersideHotel and Marina, in Tampa, Florida;

3)An award from the AAAHC Institute on behalf of their organization, after making a poster presentation about their activity at the AAAHC Achieving Accreditation Meeting, in Tampa, Florida, March 17-18, 2017.*

No other awards and/or compensation will be offered in lieu of those stated directly above. Meals and other expenses will be the sole responsibility of the winning organization(s). *The AAAHC Institute reserves the right to refuse to award items 1, 2, or 3 as described above, if the review panel finds that no submission sufficiently complies with the criteria established to evaluate entries.

Only submissions from organizations accredited by AAAHC, from June 1, 2016 up to and including March 31, 2017 are eligible for consideration. Organizations that employ an AAAHC/AAAHC Institute officer or director are not eligible for this award program.

** NOTE: Organizations may submit only one (1) QI study; multiple entries will not be considered.**

Due to an anticipated high volume of submissions, the AAAHC Institute will notify only those entrants who are finalists. Notification of finalists will take place on/by October 24, 2016. Recommendations of the Expert Panel will be submitted to the AAAHC Institute Board for review and approval. The decisions of the Board will be final.

Organizations submitting study reports to the AAAHC Institute for this program agree to release from liability, indemnify, and hold harmless AAAHC and the AAAHC Institute, and their employees, directors, officers, members and any other agents against all actual and direct losses suffered, and all liability to third parties arising from or in connection with participating in the award program.

Please do not hesitate to contact Naomi Kuznets, PhD, AAAHC Institute Vice President & Senior Director, ( or 847-853-6079) or Belle Lerner, MA, AAAHC Institute Assistant Director ( or 847-853-6078) if you have any questions.

Program void where prohibited.

QI Study Submission Agreement (Page 2 of 2)

AAAHC Institute for Quality Improvement

Bernard A. KershnerInnovations in Quality Improvement Award Program 2016-2017

Name of Study:

Contact Person:

Organization:

On behalf of ______(Name of Organization), I agree to the terms of Bernard A. Kershner Innovations in Quality Improvement Award Program 2016-2017 (Award Program), as described in the both pages (1 and 2)of this QI Study Submission Agreement document.

I attest that the information included in the submission for the Award Program is accurate and truthful to the best of my knowledge.

I will not include any HIPAA prohibited patient identifiers in my submission. I agree to make available de-identified patient documentation of the QI study being submitted, to the AAAHC Institute, upon request.

By making a submission to theAward Program, I agree to allow the AAAHC Institute to indefinitely use all, or portions of, the submission for educational and/or promotional purposes.

I also agree that if chosen as one of the 6 finalist organizations, my organization will produce a poster, in coordination with AAAHC Institute staff, and make a poster presentation at the AAAHC Achieving Accreditation Meeting, at the Tampa Marriott Waterside Hotel and Marina, in Tampa, Florida, March 17-18, 2017.

I agree to release from liability, indemnify, and hold harmless AAAHC and the AAAHC Institute, and their employees, directors, officers, members and any other agents against all actual and direct losses suffered, and all liability to third parties arising from or in connection with participating in the Award Program.

______

Authorized Organizational RepresentativeDate

Sign and Print Name

To submit:

Print out and complete this document, scan it, and save it to your hard drive.
Send the electronic file of this completed document and your QI study, with the 10 elements (AAAHC Handbook Chapter 5, Subchapter I, C) identified, via email to .
Receipt will be confirmed by a return email.
If you do not receive a confirmation of receipt by return email, the document(s) has not been received and will not qualify for consideration.

Thank you for submitting your QI study to the 2016-2017 “Innovations in Quality Improvement Award.”

Accreditation Association for Ambulatory Health Care, Inc.

5250 Old Orchard Road, Suite 250, Skokie, Illinois 60077

Phone: (847) 853-6060 Fax: (847) 853-6118