Nominee:
Business
Address:
City:
State:
Zip:
Work Phone:
Nominated
by:
Nominator's
Email Address:
Please complete the following information.
The
nominee is a member of MoAHQ:
Is
the nominee involved in other professional organizations:
If yes,
list organizations:
The
nominee is currently involved in quality management:
Does the nominee hold any certification in Quality?
If yes,
list certification:
Years of service in healthcare?
Years
of service in quality profession?
Educational
Background:
The
nominee is directly involved in Quality Management through practice,
teaching administration or research. Areas involved:
The
nominee contributes actively in their role in supporting the mission
of the organization and assists with development and implementation
of the strategic plan. Examples of strategic planning involvement
and mission support:
The
nominee has demonstrated leadership within the practice setting
(leadership can be in the formal designated role as defined by position
or can be defined by project responsibility). Example:
The nominee has demonstrated expertise in quality management through
the application of an in-depth knowledge of quality management principle
and practice. (Specifically list techniques utilized to apply quality
principles with samples such as PDCA (Plan Do Check Act), NCQA (National
Committee for Quality Assurance) Quality Template, QAPI (Quality
Assessment Performance Improvement), project completion report,
DMAIC (Define, Measure, Analyze, Improve, Control)(Six Sigma), and/or
accreditation awards; Baldrige Award Application, JCAHO (Joint Commission
on Accreditation for Healthcare Organization), URAC (AAHC) (American
Accreditation HealthCare Commission), NCQA (National Committee for
Quality Assurance), Missouri Quality Award, etc.). Explain:
The nominee has made a distinguished contribution to quality management.
Contributions are recognized on a local, state or national level.
(Please list specific accomplishments or contributions that “distinguish”
professional. Ex. Specific project with timeframes and outcome of
project, improvement to process with dollar impact noted or reduction
in errors noted).
The
nominee has communicated a positive image of quality management
to the public. Explain:
Other
examples of characteristics you wish to provide.
