EASE Online – Registration

Thank you for your interest in registering for the Education and Sleep Environment (EASE) Project for hospitals. Please complete the information below pertaining to your hospital and your team for registration into the project. Following receipt of your registration, you will receive access to the materials for data collection, quality improvement, and education as part of the project.

Please note: If you do not have all of the requested information currently at your disposal, you may still complete the registration form. Should you have any questions regarding EASE, please contact Hayley Southworth at (614) 846-6258 or via email at hsouthworth@ohioaap.org.

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EASE Project Leader for your Institution

Name *

First

Last Name *

Last

Credentials

Email Address *

Preferred Telephone Number

EASE Project Core QI Team

The EASE project can be completed by one hospitalist; a supporting QI team aids in success; this team is usually comprised of a physician leader, hospital administrative leader (such as GR staff), and QI staff member. Other team members (such as nursing leadership, child life specialists, etc) are encouraged. Please complete the information below for all additional team members participating in the project.

Would you like to register additional members of your core QI Team? --- Yes - 1 Additional Yes - 2 Additional Yes - 3 Additional No - I do not want to register additional members for my QI Team

EASE Project Core QI Team - Additional Team Member #1

Name

First

Last Name

Last

Credentials

Email Address

Preferred Telephone Number

Role

Physician, Hospital Administrator, QI Staff, Nurse, MA, etc.

EASE Project Core QI Team - Additional Team Member #2

Name

First

Last Name

Last

Credentials

Email Address

Preferred Telephone Number

Role

Physician, Hospital Administrator, QI Staff, Nurse, MA, etc.

EASE Project Core QI Team - Additional Team Member #3

Name

First

Last Name *

Last

Credentials

Email Address

Preferred Telephone Number

Role

Physician, Hospital Administrator, QI Staff, Nurse, MA, etc.

EASE Project Core QI Team - Additional Team Member #4

Name *

First

Last Name *

Last

Credentials

Email Address

Preferred Telephone Number

Role

Physician, Hospital Administrator, QI Staff, Nurse, MA, etc.

EASE Project Core QI Team - Additional Team Member #5

Name *

First

Last Name *

Last

Credentials

Email Address

Preferred Telephone Number

Role

Physician, Hospital Administrator, QI Staff, Nurse, MA, etc.

Hospital Information

Hospital Name *

Street Address *

Street Address 2 (Suite/Building/Etc.)

City *

State * ----- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code *

Phone Number *

Project Requirements

- Implementing a hospitalist based quality improvement project, which includes collecting and sharing data
- Collecting data 3 times as required in the project timeline
- Submitting PDSA Worksheets 3 times as required in the project timeline
- Acknowledging that the tools from the Ohio AAP and activities of the project will not be spread or conducted without our knowledge and permission

By typing your name in the box below, you agree to fully engage in the project by doing all of the above activities. *