Quality / Outcomes Management
Request Form
Requestor:
Request:
New
Revised
Department:
Department
Children's Hospital
Digestive Disease Center
Hollings Cancer Center
Heart & Vascular Center
IOP
Medicine Acute and Critical Care
Muskuloskeletal Services
Neurosciences
Perinatal
Surgical Acute and Critical Care
Transplant Center
Other
Email:
@musc.edu
Due Date:
mm/dd/yyyy
Phone:
Pager:
State your problem / need:
How do you know this is a problem / need?:
When was this problem first identified?:
Who owns this process?:
What metrics / data elements are to be used?:
Does this project support a pillar goal?:
Yes
(list below)
No
Service
How:?:
People
How:?:
Quality
How:?:
Finance
How:?:
Growth
How:?:
Will the anticipated outcome of this project affect more than your immediate area?:
Yes
No
Can you identify the beginning and end points of
the process?:
Who are the internal / external customers affected by this project (please list all)?:
List all the people involved in this project:
Who is the champion of this project?:
What is your desired outcome?:
Decision Support
Education
Presentation
Report
Research
Paper
Process Improvement
Format:
pdf
ppt
Where are your data?:
Keane / UHC / Data Mining
Chart Review
To be collected by requestor
Other
# of charts
# of elements
Quality / Outcome Needs:
Benchmarking
Education
Form Creation
Process Evaluation
PI Recommendation
Data needs:
Data collection
What form do you desire data to be in?:
Excel
CSV
Access
Who will enter / update and maintain the data?:
Statistics Needs
Analysis of data
Education
Patient Satisfaction Results
Survey design and / or analysis
What is the level of yourstatistics knowledge?:
Unfamiliar
Basic
Proficient
Please provide further information about this project below:
Project: Diana Hirshman | Web: Michael Irving | Date: January 2008
- MUSC Medical Center Intranet -