Request for Cppcfamily Team Practice Review

Request for CPPCFamily Team Practice Review

Practice ReviewRequest Guidelines

1. The CPPC Family TeamPractice Review is a learning framework for providers that explores shared decision making and family centered practice on family teams, often when there has been a process element or outcome that was confusing to partners.
2. A trained neutral facilitator from The Opportunity Alliance’s Mediation program will guide the conversation. A member of Southern Maine CPPC Practice Committee who is not involved in the case will provide secondary support.
3. This providers-only meeting is about improving the working relationships and shared understanding among providers on the team. We strictly adhere to the principle of "nothing about us without us," focusing on practice and partnership among providers, and steering away from decisionsabout the family.
4. If a practice complaint originated from the family, a formal client grievance process can be initiated by the family at the specific organization(s) with which the family has the complaint.Every organization has a formal complaint process. Please contact the appropriate organization(s) for more information. Family Team Practice Reviews are not designed to address client grievances.
5. To request a Family Team Practice Review from the Southern Maine CPPCPractice Committee, please complete this form and return it to or . You can also find it online at

Screening Questions

Did the family initiate (and/or do they share in)a practice complaint? yes ☐no ☐

If yes, the Family Team Practice Review is not designed to address thiscomplaint. Families and providers are encouraged to access the relevant organization’s formal grievance process.

Is this a provider-to-provider opportunity for shared learning and practice improvement? yes ☐no ☐

If yes, please complete the following request form.

Request Information

Your Name Click or tap here to enter text. Role Click or tap here to enter text.

Organization Click or tap here to enter text. Phone Click or tap here to enter text.

Email Address: Click or tap here to enter text.

Initials of family served by team Click or tap here to enter text.

In what community does the family live? Click or tap here to enter text.

Children related to this request (Must include age and gender)

Brief description of reason for request: (If request is related to a specific Family Team Meeting, please include date of meeting).

Click or tap here to enter text.

Team members related to this request: (Must include all information)

Additional Information

Practice Committee Family Team Practice Reviews are designed to address two core strategies of CPPC: Family Centered Practice and Shared Decision Making. Which of the following led you to request a Practice Review?(Check all that apply)

Family Centered Practice

☐Respectful treatment of family

☐Honesty/transparency with family

☐Compassionate approach to family issues

☐Parent self-determination

☐Providing message of hope/resilience

☐Trauma informed practice

Shared Decision Making

☐Common vision and goals

☐Agreed-upon ways to evaluate outcomes

☐Clear roles and responsibilities

☐All team members have a voice

☐Development and follow through of Family Plans/next steps

☐Trust among team members

☐Effective, open and timely communication

☐Successful management of conflict

☐Effective, appropriate shared leadership

What do you hope to achieve if a Practice Reviewis held?

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Administrative Use Only

Date CPPC received request:Click or tap to enter a date.

Received by: Click or tap here to enter text.

Practice Committee Approval: ☐Yes ☐No

Organizer: Click or tap here to enter text.

Scheduled Practice Committee Observer: Click or tap here to enter text.

Practice Review date:Click or tap to enter a date.