1 LMBP Quality Improvement (QI) Data Submission Form

Title: Laboratory Medicine Best Practices Project (LMBP)

OMB Control Number: 0920-0848

Expiration Date: 5/31/2013

LMBP Quality Improvement (QI) Data Submission Form

Non Material Change

Instruction: To assist you with completing this form, please refer to the Instructions

Submitter’s Name:­­­­­­­­­­­­­ ­­­­­­­­­­­­________________________________ Today’s Date: ________________

Position: ________________________________________

Institution: ______________________________________

Organization / Department: ________________________

E-mail: _________________________________________ Phone: _______________________

Mailing Address: _________________________________

City: ________________________ State: _____________ Zip Code:_____________________

Do you want your organization to be identified ____ or remain anonymous? ____

If identified, please provide the name(s) of person(s) the data is attributed to:

__________________________________________________________________

If any information on the submission form is not familiar to you or needs explanation, please note “not familiar” as an answer choice.

Thank you for taking the time to submit your information.

LMBP Quality Improvement (QI) Project/Study Summary Form

(Note: Please complete separate form for each study/evaluation you conducted)

You can “check” boxes by double left clicking on them. If you do not have room to fill in the answer, use the next page and refer to question number.

Background Information	QI Project/Study	QI Practice	Outcome Measures	Results/Findings/ Considerations
1. LMBP Quality Problem (topic): ____________________________ 2. a.Quality Problem/ Issue Description b. IRB approval obtained Waived YES NO {Stop here and submit form, our staff will follow up with you} ** 3. Funding Source(s): In-house Manufacturer: Describe: Grant/Contract: Describe: Other – Describe: 4. Facility Description a. Facility type Hospital: Type:_______________ Physician Office Laboratory Public Health Laboratory Blood Center Independent laboratory Other: Specify_____________________ b. Number of Beds N/A <100 beds 100-300 beds >300 beds c. Total test volume per yr ____________	5. a.QI Project Design: Observational: Pre-post (before-after) Observational: Case – Control Controlled Experiment/ Randomized Control Time Series Cohort Other: Specify___________________ b. Briefly describe aim for the design: 6. QI Project Setting: Emergency Dept. ICU/PICU/NIUC Ob/Gyn Hospital inpatient Physician office Hospital outpatient Other-Describe: 7. Sample Size and Description: (describe totals for new and usual practice) a. Sample is: Tests Specimens Patients b. Sample size for New QI Practice is: c. Sample size for Original (Usual) Practice ( if applicable) is :	8. Describe Original (Usual) Practice: 9. Describe New Intervention/ Practice: 10. Practice Duration a. New QI Practice Start date (mo/yr): _________ / End date (mo/yr): __________ Practice is Ongoing: YES NO b. Original (Usual) Practice Start date (mo/yr): ________ / End date (mo/yr): _________ Practice is Ongoing: YES NO 11. Resource Requirements/Costs: A. Staff: Medical technologist Laboratory phlebotomist Nursing personnel Resident Medical student Physician B. Training: __________________________________ __________________________________ C. Equipment/Supplies: __________________________________ D. Cost: __________________________________ E. Other:___________________________	12. Outcome Measure(s) Description: Description: ___________________________________ ___________________________________ How determined: ___________________________________ ___________________________________ ___________________________________ 13. Measurement Duration a. New QI Measurement Start date (mo/dd/yr): ____/____/____ End date (mo/dd/yr): ____/____/____ b. Original (Usual) Practice Measurement Start date (mo/dd/yr): ____/____/____ End date (mo/dd/yr): ____/____/____ 14 a. Recording method (how data was collected / note any differences between the original (usual) and new/intervention practices): Occurrence logs Incident / adverse events reports Audit – direct observation Electronic information system monitoring Other Please Describe each checked method: ___________________________________ ___________________________________ ___________________________________ 15. Potential Limitations to the QI Project/Study: __________________________________	16. Results/Findings (as related to /outcome measure): 17. Data Analysis- Significance (if applicable): For Pearson correlations F-Test T-Test Fischer Exact Chi-square Odds Ratio Rates Other: ____________________ 18. Barriers to Implementation: 19. Requirements to sustain the new QI practice: 20. Lessons Learned: