Form to Formally Join a PA PQC 2022 Initiative

Directions:

Birth hospitals and/or NICUs can formally join or re-commit to their existing PA PQC initiative(s) by submitting this form to: (1) select the initiative(s) for the Implementation Period; (2) create or update their multi-disciplinary PA PQC healthcare team (including representatives from the participating hospitals); (3) agree to work towards the PA PQC initiative’s goals; and (4) agree to follow the PA PQC expectations for the Implementation and Sustaining periods.

Please review all the information and documents at https://www.whamglobal.org/pa-pqc-initiatives before completing this form.

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* 1. Please enter the name of the Birth Hospital and/or NICU that is joining a 2022 PA PQC Initiative. (If the hospital is part of a system, please use the following nomenclature: "System Name - Hospital Name.")

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* 2. Please enter the name and title of the person completing this form to formally join a 2022 PA PQC Initiative.

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* 3. Please select the PA PQC 2022 initiatives your hospital would like to join.

Maternal Substance Use Initiative (which includes the maternal OUD initiative as well)

Substance Exposed Newborn Initiative (which includes the NAS initiative as well)

Immediate Postpartum LARC Initiative

Moving on Maternal Depression (MOMD) Initiative

PA AIM Severe Hypertension Initiative

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* 4. Please indicate whether your birth hospital has reviewed the information on the “2022 PA PQC Initiatives” webpage (https://www.whamglobal.org/pa-pqc-initiatives), including the document(s) posted under the section entitled “Initiative Goals and Key Interventions” for the PA PQC 2022 initiatives in which your hospital will be participating. (A "Yes" response is needed to join.)

Yes

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* 5. Please indicate whether your birth hospital understands and agrees to work towards the goals of the PA PQC 2022 initiative(s) that your hospital selected in Question 3 and to work towards the "Expectations" for the "Implementation Period" and "Sustaining Period" that are outlined on the "2022 PA PQC Initiatives" webpage (https://www.whamglobal.org/pa-pqc-initiatives). If you do not understand, please contact the PA PQC at papqc@whamglobal.org. (A "Yes" response is needed to join.)

Yes

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* 6. Please indicate whether your birth hospital agrees to email the PA PQC at papqc@whamglobal.org a current list of your PA PQC healthcare team members using this Excel form. (If helpful, please feel free to also ask the PA PQC to email you a current copy of the the contact list for your hospital to review.) (A "Yes" response is needed to join.)

Yes

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* 7. Please indicate whether your birth hospital gives permission to the PA PQC to publicly disclose the birth hospital’s participation in the PA PQC and in the selected PA PQC initiatives.

Yes

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* 1. Please enter the name of the Birth Hospital and/or NICU that is joining a 2022 PA PQC Initiative. (If the hospital is part of a system, please use the following nomenclature: "System Name - Hospital Name.")

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* 2. Please enter the name and title of the person completing this form to formally join a 2022 PA PQC Initiative.

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* 3. Please select the PA PQC 2022 initiatives your hospital would like to join.

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* 7. Please indicate whether your birth hospital gives permission to the PA PQC to publicly disclose the birth hospital’s participation in the PA PQC and in the selected PA PQC initiatives.

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* 8. Please include any questions or feedback you have about the PA PQC's 2022 initiatives.