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1 This printable application is provided for your reference only. Please enter yourr application information online at Completed applications must be submitted on or before August 8, Mentored Quality Improvement Impact Activity Application to Participate IMPORTANT: As a prerequisite for applying, hospitals must be locatedd in the U.S. and have at least one insulin pen device currently on formulary for dispensing to inpatients. Please confirm that your hospital is located in the U.S. and that you have at least one insulin pen device currently on formulary for dispensing to inpatients. Yes No Informationn Impact s should include key individuals (managers and front linee staff) from departments throughout the hospital. The Leader will serve as the primary contact for the ASHP Advantage Mentors throughout the program. All correspondence will be sent to the Leader. Leader Address 1 Address 2 Member 1 Member 2 Member 3 Member 4 Member 5 City State Zip Office Phone Fax E mail

2 Hospital Information of Hospital City State Zip Occupied Beds less than more than 500 Hospital Type Academic Health Science Center Community Teaching Hospital Community Hospital (non teachingor Medical Center Other (pleasee describe) Is this hospital part of a healthh system? VA Hospital Yes (please enter the name of the system) No Use of Insulin Pens What is your best estimate of the percentage of subcutaneous insulinn doses delivered in your hospital to inpatients by pen device? 10 25% 26 50% 51 85% >85% Whether your use is high or low, how do you believe your hospital could benefit from participating in this impact activity? (limit 6000 characters) Which of the following insulin pen devices are currently on formularyy for dispensing to inpatients at your hospital? Please select only those products that are available and on the formulary in a pen device for inpatients. (Select all that apply.) Rapid acting Insulin aspart (Novolog) Insulin glulisine (Apidra) Insulin lispro (Humalog) Intermediate acting Insulin isophane (Humulin N) Long acting Insulin glargine (Lantus) Insulin detemir (Levemir) Insulin mixes 70% Aspart protamine suspension / 30% aspart solution (NovoLog Mix 70/ /30) 75% Lispro protamine suspension / 25% lispro solution (Humalog Mix 75/ /25) 50% Lispro protamine suspension / 50% lispro solution (Humalog Mix 50/ /50) 70% NPH / 30% regular (Humulin 70/30) Mentored QIIA Application Pen Safety Page 2 of 6

3 Which of the following insulin 3 ml vials are currently on formulary for dispensing to inpatients at your hospital? Pleasee select only those products thatt are available and on the formulary in a 3 ml vial for inpatients. (Select all that apply.) Insulin lispro (Humalog) Insulin regular (Humulin R) Insulin isophane (Humulin N) What do you think are the major concerns (confirmed or perceived) related to the use of insulin pens in your hospital? (limit 600 characters) Have prior attempts been made to improve the safe and appropriatee use of insulinn pens at your hospital? If so, briefly describe what was done and the success of these initiatives. have published any information about your previous improvement initiatives, please provide the specific citation. (limit 600 characters) Briefly describe anticipated barriers to implementing process improvement(s) in the use of insulin pens in your hospital. (limit 600 characters) Skills and Hospital Information Do any members of your Impact currently serve as a member or chair of any of the following committees at your hospital? (Check all that apply..) Chair Member No one on the team serves on this committee Medical Executivee Quality Safety Pharmacy and Therapeutics Glycemic Control Other (please list) Do any members of your Impact have experience developing or implementing process improvements related to medication safety? Yes No Mentored QIIA Application Pen Safety Page 3 of 6

4 answered Yes above, briefly describe. This impact activity involves collecting observational data to help participants identify potential risks related to the use of insulin pens in your hospital and then assess the effect of your quality improvement efforts. ASHP will provide data collection tools and instructions and summarize results for your hospital after dataa are submitted. Within the past 12 months, have members of your Impact had experience collecting dataa using direct observation of a patient care process? Yes No answered yes above, briefly describe. Within the past 12 months, have members of your Impact had experience conducting an audit of medication use and storage? Yes No answered yes above, briefly describe. This impact activity requires that you send a hyperlink to a brief online survey to the hospital s inpatient nursing staff. The survey is developed by ASHP, and results will be collated by ASHPP and returned to you for your use. You will receive suggested language to customize the message with the survey link that is specific to your hospital. The Impact will be responsible for distributing the and the survey link. Do you have access to the distribution list of the entire inpatient nursing staff to accomplish this requirement? Yes No answered no above and have an alternative way of distributing the survey link, briefly describe. Mentored QIIA Application Pen Safety Page 4 of 6

5 Which of the following have been implemented at your hospital? (Check the box corresponding to your team s assessment of your hospital s degree of implementation.) Not Implemented Limited / Partially Implemented Widely/Fully Implemented Computerized physician order entry Electronic medical records Barcode medication administration Electronic medication administration record Hospital policy and procedure for glycemic control in the ICU Hospital policy and procedure for glycemic control on general medical and surgical floors Hospital policy and procedure for insulin pen use Inservice education for insulin pen use have partially or fully implemented any of the following, pleasee specify the software vendor. Computerized physician order entry: Electronic medical records: Barcode medication administration: Electronic medication administration record: Mentored QIIA Application Pen Safety Page 5 of 6

6 Obligations and Responsibilities By applying for the Mentored Quality Improvement Impact Activity for Insulin Pen Safety, the Impact indicates that it has reviewed the activity description (www.onepenonepatient.org) and acknowledges that, if selected to participate, it is responsible for implementing at least one process improvement intended to improve the safe and appropriate use of insulin pens at its hospital. Specifically, the through its Leader agrees to the following: (Check ALL boxes.) Participate in CE webinar on September 4, 2014, or view archivedd webinar Participate in all 4 Mentored Conference Calls dates TBD in September 2014, November 2014, January 2015, and May 2015 (Note: the calls will be recorded and archived) Submit to ASHP Advantage staff 30 days before the second Mentored Conference Call Existing hospital protocols and policy & procedure documents related to glycemic control and insulin pen use Collect and report baselinee data using the tools provided at least 2 weeks before the second Mentored Conference Call Develop, submit, and implement a plan for a process improvement intended to improve safe and appropriate use of insulin pens in the hospital within days after the second Mentored Conference Call Collect and report post implementationn data (similar to the initial observations) at least 2 weeks beforee the final Mentored Conference Call Submit final report in PowerPoint format (template provided) within 2 weeks of final Mentored Conference Call Hospital Support and of Senior Leader (e.g., C Suite level) who supports this project Senior Leader : Senior Leader : By selecting the I Agree button on the online application, the Leader acknowledges and agrees to ALLL of the team obligations as outlined above. In addition to your online acceptance, a signed and completed Applicant Agreement must be faxed to ASHP. The Applicant Agreement requires signatures of the Leader and Hospital Senior Leader and is available via a link at the completion of this application. Mentored QIIA Application Pen Safety Page 6 of 6

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