acpa team approval: 2020 sample application · orthodontia/pediatric dental. after all patients are...

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ACPA TEAM APPROVAL:

2020 SAMPLE APPLICATION

Standard1:TeamComposition

TeamInformationUponapproval,fieldswillbeusedfortheofficialteamlisting*

TeamID

IfyoudonotknowyourteamID,[email protected].

99999

ApplicationType

Cross-SpecialtyTeam(bothcleftpalateandcraniofacial)

1. TeamListingInformation

NameofTeamandInstitution*

TeamACPA

mailto:[email protected]

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TeamAddress

CompanyName ACPA

Street* 1504EFranklinStSte102

City* ChapelHill

State/Province* NC

Zip/PostalCode* 27514

Country* UnitedStates

PrimaryEmail [email protected]

PrimaryPhoneNumber 919.933.9044

PrimaryFaxNumber (Noresponse)

TeamWebSite

www.acpa-cpf.org

PatientAgeRangeFrom*

0

PatientAgeRangeTo*

99


http://www.acpa-cpf.org/

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LeadTeamMembers

2. TeamCoordinator(s)

Theteamincludesadesignatedpatientcarecoordinatortofacilitatethefunctionandefficiencyoftheteam,ensuretheprovisionofcoordinatedcareforpatientsandfamilies/caregiversandassisttheminunderstanding,coordinatingandimplementingtreatmentplans.

TeamCoordinator1

FirstName* Erin

LastName* Mallis

Designations(i.e.MD,DMD,PhD)* N/A

Specialty* Coordinator/Administrator

Email* [email protected]

Addanothercoordinator

3. Describethespecificrolesandresponsibilitiesoftheteamcoordinator(s)andhowthey

ensurecoordinatedcare.

Therolesandresponsibilitiesoftheteamcoordinatorshouldincludehowtheyinteractwithpatients/familiesandmembersoftheteam.

4. TeamLeader/Director


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TeamLeader/Director1

FirstName* Alyssa

LastName* Kirkman

Designations(i.e.MD,DMD,PhD)* N/A

Specialty* Coordinator/Administrator

Email* [email protected]

Addanotherleader

5. CraniofacialTeamLeader(mustbetrainedintranscranialsurgery)

Thecraniofacialteammustincludeasurgeontrainedintranscranialcranio-maxillofacialsurgery.

FirstName* Mark

LastName* Johnson

Designations(i.e.MD,DMD,PhD)* MD

Specialty* CraniofacialPlasticSurgery

EmailAddress (Noresponse)

6. Describethebackground/educationalandtrainingqualificationsoftheteam’scraniofacial

surgeon.

Example:MarkJohnsonreceivexxtrainingatABCHospitalandxxtrainingatXYZMedicalCenter.


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7. RegularTeamMembers

Allregularlyparticipatingteammembersshouldbelistedinthissection.

Theteammustincludespeech-languagepathology,surgical,andorthodontic

specialties.Pleaselistthesecoreteammembersfirst.

RegularTeamMember1

FirstName* John

LastName* Smith

Designations(i.e.MD,DMD,PhD)* MD

Specialty* PlasticSurgery


Addanothermember

RegularTeamMember2

FirstName* Jane

LastName* Doe

Designations(i.e.MD,DMD,PhD)* MA

Specialty* Speech-LanguagePathology


Addanothermember

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RegularTeamMember3

FirstName* William

LastName* Williams

Designations(i.e.MD,DMD,PhD)* DMD

Specialty* Orthodontics


Addanothermember

Regular Team Member 4

FirstName* Harry

LastName* James

MD

Specialty* Otolaryngology

Designations(i.e.MD,DMD,PhD)*

EmailAddress

Addanothermember

(Noresponse)

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8. ListindividualsthattheteamworkswithonareferralbasisthatareNOTregularteam

members.

Theteammustdemonstrateaccesstoprofessionalsinthedisciplinesofpsychology,social

work,audiology,genetics,dentistry,otolaryngology,andpediatrics/primarycare.

Craniofacial/Cross-Specialtyteamsmustalsodemonstrateaccesstoprofessionalsinthe

disciplinesofneurosurgery,ophthalmology,andradiology.

Ifanyoftheabovespecialtiesareregularteammembers,listthemintheRegularTeamMemberssectiononthepreviouspage.

Doesyourteamhaveaccesstootherprofessionalswhoarenotregularteammembers?*

Yes

Regular Team Member 5

FirstName* Martin

LastName* Thomas

MD

Specialty* Pediatrics/PrimaryCare

Addanotherprofessional

Designations(i.e.MD,DMD,PhD)*


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OtherProfessional2*

FirstName* Mary

LastName* Thompson

Institution/Practice* ABC

Designations* LSW

Specialty* SocialWork


OtherProfessional1*

FirstName* Joe

LastName* Sample

Institution/Practice* ZZZ

Designations* PhD

Specialty* Psychology


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OtherProfessional4*

FirstName* Jim

LastName* Example

Institution/Practice* XYZ

Designations* MD

Specialty* Genetics


OtherProfessional3*

FirstName* Sarah

LastName* Jones


Designations* AuD

Specialty* Audiology


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OtherProfessional6*

FirstName* Tom

LastName* Daniels


Designations* MD

Specialty* Neurosurgery


OtherProfessional5*

FirstName* Lisa

LastName* Test

Institution/Practice* XDentalPractice

Designations* DDS

Specialty* PediatricDentistry


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OtherProfessional7*

FirstName* Emily

LastName* Jacobs


Designations* MD

Specialty* (Noresponse)


OtherProfessional8*

FirstName* Bill

LastName* Morris


Designations* RT

Specialty* Radiology


Standard2:TeamManagementandResponsibilitiesResponses should describe normal team processes outside of any temporary changes due to COVID-19.

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Theteamhasamechanismforregularmeetingsamongcoreteammemberstoprovidecoordinationandcollaborationonpatientcare.

Note:

Teammeetingsrefertomeetingsamongmultidisciplinaryteammembersinwhichpatientfindingsarediscussedandteamrecommendationsaremade.Ataminimum,teammeetingsmustincludethespeech-languagepathologist,surgeon,andorthodontist.

Teamorpatientevaluationisthepatient-facingcomponentoftheteam'sprocess,inwhichpatientsreceiveface-to-faceevaluationbythedisciplinesrepresentedontheteam.

9. Howoftenareteammeetingsheld?

__ Quarterly

__ Monthly

__ Bi-weekly

__ Weekly

__ Other, please specify...: Team meetings should be frequent enough that the participants are able to remember

the evaluations for the patients discussed.

10. Inwhatformatareteammeetingsheld?

__ Face-to-face

__ Not face-to-face but in real time (e.g. conference call)

__ Neither

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Explainhowtheteamensuresallpatientsarediscussedcollaborativelyamongatminimumthe

coreteammembers(speech-languagepathologist,surgeon,andorthodontist).

Ataminimum,thecoreteammembersshoulddiscusseachpatientandformulateamultidisciplinarytreatmentplan.Ifthisdoesnothappeninrealtime,eitherinpersonorusingelectronicmodalities,theteammustjustifyhowitsmethodensuresthatthereisdialogamongthosespecialties.Simplereportingoffindings/recommendationsindividuallythroughacentralchartorthroughacoordinatorisnotcompliant.

11. Areteammeetingsheldthesamedayasthepatientevaluation?

__ Yes

__ No

Howdoestheteamensurethatpatientinformationisnotforgottenormissed?

Example:Theteamcoordinatoremailsthelistofpatientstobediscussed2dayspriortotheteammeeting.EachparticipanthasaccesstotheirnotesviatheEMRandisresponsibleforreferringtothosenotesduringtheteammeetingwhengivingtheirreport.Theteammeetingreportisthensenttoallparticipants,whoareresponsibleforreviewingthereportandattestingthattheyagreewiththecontent.

12. Doesthepatienthavetheopportunitytoreceivesame-dayface-to-faceevaluationbyall

coreteammembers(speech-languagepathologist,surgeon,andorthodontist)?

__ Yes

__ No

This question will only be shown if you indicate Neither in the previous question.

This question will only be shown if you indicate No in the previous question.

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Describehowtheteamensuresthatmultidisciplinaryteamevaluationlinkedto

multidisciplinaryteamreportingoccurs.

Ifface-to-faceevaluationsdonotoccursame-day,theteammustindicatehowtheteamensurespatientsreceivemultidisciplinaryevaluations,integratingfindingsandrecommendationsfromalldisciplines.Evaluationsshouldbewithinacloseenoughtimeframethatitisclearthatallthreeprofessionalsareevaluatingthepatientatthesamestage.

Example:ThecoordinatorassignsappointmentsforthepatientfortheSLP,surgeryandorthodontiawithinthesame30dayperiod,anddoesaphoneassessmentifappointmentsforanyotherteamspecialistsareindicated.

13. Describetheprocedureusedbytheteamifoneormoreoftheusualcoreteammembers

cannotattendateammeeting.

Example:Doessomeonesubstituteinthisprovider'splace?Isthemeetingrescheduled?

14. Describehowapatientreceivescomprehensivesame-dayface-to-facemultidisciplinary

evaluation.Includedescriptionofatypicalteamevaluationofpatientsandhowthisleadsto

integrateddecisionmaking.

Describetheproceduresofatypicalteamevaluationandhowtheteammemberscollaborateduringtheevaluationandafterwardstomakedecisionsandformulaterecommendationsinamultidisciplinarymanner.

Example:Frombirthtoage8,allpatientsreceiveafullteamevaluationyearly.Patientsreceiveapsychosocialscreening,pediatricscreening,andassessmentsbySurgery,SLP,ENT,Audiology,andOrthodontia/pediatricdental.Afterallpatientsareseen,theteammeetstodiscusseachpatientandreachateammultidisciplinaryrecommendation.Afterage8,intervalsoffullteamevaluationaredeterminedbyneedanddiagnosis.Patientsalsoseeindividualspecialistsasneeded.


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15. Describehowtheresultsoftheteammeetingforeachindividualpatientarerecordedand

becomeapartofthepatient’steamreport.

Whoisresponsibleforrecordinginformationfromthemeeting?Wheredoesthisinformationgetrecorded?

Example:Duringtheteammeeting,eachpatient’sfindingsarediscussedbythepertinentspecialist,andthentheentireteamdiscussesandagreesonrecommendations.Notesaretakenbytheteamcoordinator.Ateamreportisauthoredbytheteamleader.ThereportisanEMRtemplatethatincludeseachspecialistfindingsasimportedfromtheindividualreportsintheEMR,andrecommendationsgeneratedafterteamdiscussion.ThereportissavedasamultidisciplinaryteamreportintheEMR.ThecoordinatorisresponsibletoprovidethereporttothefamilyandthePrimaryCareProvider.

16. Uploadpagesfromonepatientteamreportthatdocumentstheparticipationofthe

speech-languagepathologist,surgeonandorthodontist.Iftheteamisacraniofacialorcross-

specialtyteam,thereportshouldalsodocumenttheparticipationofthetranscranialsurgeon.

Ateamreportmustbeasingledocumentthatidentifies:

Theconditionbeingtreated,specialtiesinvolved,andyearoftheevaluation.Redactthemonthanddayofevaluation.Thefindingsforeachspecialtyevaluationandspecificteamrecommendations.Theyearofteammeetingthatgeneratedthereportandtheindividuals(withspecialty)whoparticipatedintheteammeeting.Thepersonwhohasgeneratedtheteamreport.

Placeastarbythesection(s)ontheattachmentsthatdocumentcompliancewiththestandard.Omitidentifyinginformationandlimittheattachmenttofivepages.

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Theteamhasamechanismforreferraltoandcommunicationwithotherprofessionals.

17. Describetheprocessforinformationexchangewithschools,primarycareprofessionals,

outsideagencies,andotherprofessionalsinvolvedwiththewelfareofthepatient.

Describetheprocessforinformationexchange(i.e.referrals)foroutsideinstitutions,notinternalteammembers.BesuretocommentonbothcommunicatingwithANDreceivinginformationfromotherentities.

Example:Atthetimeofteamevaluation,consentforreleaseofrecordsisobtained,andthefamilymayindicaterecipientsfortheteamevaluation.Iftheteammeetingrevealsaneedforrecordsrequest,thecoordinatorcontactstheappropriateprovider/organization,providesthesignedrelease,andobtainstherecord,whichisscannedintotheEMR.Familiesareprovidedwithacopyofeachteamreport,whichtheyareencouragedtosharewithotherspecialistsandagenciesasneeded;additionally,theteamreportissentelectronicallytothepatient’sPCPifoneisdesignatedintheEMR.

18.UploadacopyoftheReleaseofInformationFormusedbytheteam.Thisformshouldbe

blank.Limittheattachmenttotwopages.

19. Describehowtheteamfacilitatesthetransitiontoadultcareifnotallprovidersonthe

teamtreatpatientsafterage18or21.

Arepatientsreferredelsewhere?Dopatients/familiesreceiveinformation/resources?

Example:Atage12,planningfortransitionforadultcarebeginswithdiscussionwithfamily.Atappropriateages,familiesareprovidedwithrecommendationsforprovidersforadultprimarycareandadultdentalcare.Oursurgical,orthodontic,SLPandENTprovidersprovideadultcareaswell.Resourcesforspecialneedspatientsaresuggested.Patientsaretransitionedoutofteamcarebyage21,howeverteamresourcesremainavailableasneeded.

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Theteamre-evaluatespatientsbasedonteamrecommendations.

20. Describetheprotocolforhowtheteamevaluatesapatientwithcleftlip/palateovertime

(E.g.,developmentalmarkers,age,etc.).Includewhichteammembersseepatientsatwhich

points,includingcoredisciplines(surgery,speech,andorthodontics)andreferrals.

Includeatminimumthecoreteammembersandatwhichtimepointstheyevaluatepatientswithcleftlip/palate.Includespecifictimepoints(e.g.,agesorfrequency)atwhichpatientsareseenbyorreferredtonon-coredisciplines,ifdifferentfromcoredisciplineevaluationschedule.

Example:PatientswithCL/Pareevaluatedbythefullteamyearlytillbonegraft,thenatminimumevery2years,ormorefrequentlyifneeded,untilcompletionoftreatment.

21. Provideanexampleofacraniofacialdiagnosistreatedbytheteamanddescribethe

protocolforhowtheteamevaluatesapatientwiththisdiagnosisovertime(E.g.,

developmentalmarkers,age,etc.).Includewhichteammembersseepatientsatwhichpoints,

includingcoredisciplines(surgery,speech,andorthodontics),thecraniofacialsurgeon,and

referrals.

Includeatminimumthecoreteammembersandcraniofacialsurgeonandatwhichtimepointstheyevaluatepatientswithacraniofacialdiagnosis.Includespecifictimepoints(e.g.,agesorfrequency)atwhichpatientsareseenbyorreferredtonon-coredisciplines,ifdifferentfromcoredisciplineevaluationschedule.

Theteammusthavecentralandsharedrecords.

22. Doestheteamuseastandardizedelectronicmedicalrecordforstorageofnotesand

reports?

__ Yes

__ No

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Describethemechanismsforrecord-keeping(e.g.,wherehousedandmaintained,accessto

records,etc.)

Theteamshouldhaveamechanismforkeepingrecordsthatallteammembershaveaccessto.

23. Describehowrecommendationsbecomepartofthepatientrecordwhenpatientsare

evaluatedoutsideoftheteamsetting.

Example:Theteamrequestsacopyofthereportfromrelevantevaluationsconductedoutsideoftheteamsetting.Thisreportisscannedintothepatient'smedicalrecord,andrelevantfindingsandrecommendationsareincludedinthepatientabstractsdraftedforteamprovidersaheadofeachteamclinicandaresummarizedinthepatient'snextteamreport.

Standard3:PatientandFamily/CaregiverCommunicationTheteamprovidesappropriateinformationtothepatientandfamily/caregiveraboutevaluationandtreatmentproceduresorallyandinwriting.

24. Whoisresponsibleforprovidinginformationaboutpatientevaluationandthe

recommendedtreatmentstofamiliesandpatients?Howistheinformationcommunicatedto

thembothorallyandinwriting?

Indicatetheindividualwhoisresponsibleforprovidinginformation.Includehowinformationisprovidedbothorallyandinwriting.

Theteamencouragespatientandfamily/caregiverparticipationinthetreatmentprocess.


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25. Describehowthefamily/caregiverhasopportunitiestoplayanactiveroleinthedecision-

makingprocessforthetreatmentplan.

Theteamshouldindicatehowthefamily/caregiverisinvolvedindecision-making.

26. Describehowthepatientisinvolvedinthedecision-makingprocessforthetreatmentplan

atanappropriateage.

Theteamshouldindicatehowthepatientisinvolvedindecision-making.

Theteamwillassistfamilies/caregiversinlocatingresourcesforfinancialassistancenecessarytomeettheneedsofeachpatient.

27. Describetheprocessforinformingfamilies/caregiversoffinancialandinsurance-related

resources.Thesemightincludefederal,state,andprovincialregulationsspecificallygoverning

thetreatmentofcleft/craniofacialanomalies.(e.g.,insurance,stateagencies,PublicLaw94-

142,504s,andindividualizededucationalplans).

Provideexamplesoffinancialresourcesprovidedtofamilies.

Standard4:CulturalCompetenceTheteamdemonstratessensitivitytoindividualdifferencesthataffectthedynamicrelationshipbetweentheteamandthepatientandfamily/caregiver.

28. Howdoestheteamcommunicatewithpatientsandfamiliesforwhomtheteam'slanguage

isnottheirprimarylanguage?Doestheteamuseinterpretersortranslatedmaterials?

Indicatehowtheteamcommunicatesbothorallyandinwriting.

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29. Howdoestheteamensurethatitissensitivetoethnicandculturaldiversity?Describeany

training,education,orinterventionsthatareusedbeyondhavingbilingualstaff.Trainings

requiredbytheteam'sinstitutionaswellaseducationprovidedwithintheteamare

acceptabletoinclude.

Forexample,thismaybeanannualmandatoryinstitutionalculturalsensitivityanddiversitytraining.

Theteamtreatspatientsandfamilies/caregiversinanon-discriminatorymanner.

30. Howdoestheteaminformpatientsandfamilies/caregiversoftheirrights(e.g.,patientbill

ofrights,Website,institutionalliterature,etc.)?

Aretheyprovidedmaterials,referredtothewebsite,etc?

31. ProvidealinktoorattachacopyofthePatient'sBillofRights.Aprivacypolicydoesnot

qualify.Limitattachmenttothreepages

PleasedenotehowyouwillattachthePatient'sBillofRights

_x_ Link to website

__ Upload

Pleaseattachthecompletewebaddress

http://www.acpa-cpf.org

Standard5:PsychologicalandSocialServicesTheteamhasamechanismtoinitiallyandperiodicallyassessandtreat,asappropriate,thepsychologicalandsocialneedsofpatientsandfamilies/caregiversandtoreferforfurthertreatment,asnecessary.

http://www.acpa-cpf.org/

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32. Describehowtheteamidentifiesandreferspatientsandfamilies/caregiverswhomaybein

needoffurtherevaluationandtreatmentforemotionalorbehavioralissues.Includethe

team'sprocessforidentifyingtheseissuesandthespecificteammember(s)responsiblefor

implementingtheprocess.

Theteamshouldindicatewhichteammemberisresponsibleforidentifyingemotionalorbehavioralissuesandtheirqualifications.Includeanyscreeningtoolsusedtoidentifyandreferpatientsandfamilies/caregiversinneedoffurtherevaluationandtreatment.Astatementthatallteammembersmayidentifyandrecommendevaluationforpsychosocialissuesisnotsufficient.Thereshouldbeanidentifiedindividualwhoscreensforthisinaregularandsystematicmanner.

Example:Theteam'spsychologistmeetswithpatientsandfamiliesaspartofeachteamevaluationandperformsabriefpsychosocialinterviewtoscreenforconcerns.

33. Doesamentalhealthproviderlistedasaregularteammemberevaluate/treat

emotional/behavioralissues?

__ Yes

__ No

Whomdoestheteamreferpatientsandfamilies/caregiverstoforfurtherevaluationand

treatmentofemotionalorbehavioralissues?Includetheindividual'squalifications.

ThisindividualshouldbelistedinStandard1-AccesstoOtherProfessionals.

Theteamhasamechanismtoassesscognitivedevelopment.


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34. Describehowtheteamidentifiespatientswhomaybeinneedoffurtherevaluationor

treatmentforcognitivedevelopmentissues(e.g.,learningdisabilities).Includetheteam's

processforidentifyingtheseissuesandtheteammember(s)responsibleforimplementingthe

process.

Theteamshouldindicatewhichteammemberisresponsibleforidentifyingcognitivedevelopmentissuesandtheirqualifications.Includeanyscreeningtoolsusedtoidentifyandreferpatientsandfamilies/caregiversinneedoffurtherevaluationandtreatment.Astatementthatallteammembersmayidentifyandrecommendevaluationforcognitiveissuesisnotsufficient.Thereshouldbeanidentifiedindividualwhoscreensforthisinaregularandsystematicmanner.

Example:Thenursecollectstheeducationalhistory,andtheSLPandpediatricianscreenfordevelopmentalissues.ThecoordinatorisresponsibleforfollowupofrecommendationsforChildStudyteam,EarlyIntervention,orDevelopmentalPediatricsevaluations.

35. Doesamentalhealthproviderlistedasaregularteammemberevaluate/treatcognitive

developmentissues?

__ Yes

__ No

Whomdoestheteamreferpatientsandfamilies/caregiverstoforfurtherevaluationand

treatmentofcognitivedevelopmentissues?Includetheindividual'squalifications.

Limitresponseto500words.

ThisindividualshouldbelistedinStandard1-AccesstoOtherProfessionals.


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36. Describehowpatientswithcognitivedevelopmentissuesaremonitoredovertimesothat

appropriateeducationalservicesareinplacefrominfancythroughadolescence.Ifmonitoring

isdonebyanoutsideservice(e.g.schoolsystem),explainhowtheteamensuresthatthe

patients’needsaremet.

Includetimemarkersintheresponse.Ifmonitoringisdonebyanoutsideservice,theinformationshouldbecomepartofthepatient'srecord.Iftheschoolsystemprovidesthisservice,explainhowtheteamensuresthattheevaluationsareperformedand/ortreatmentisdelivered.

Theteamconductsformalassessmentofcognitivefunctioningofpatientswhendeemednecessary.

37.Describetheteam’sprocessforconductingaformalassessmentofcognitivefunctionona

patientwhoisage4orolderandwhohasacraniofacialconditionrequiringtranscranial

surgery.Indicatethetypesofcognitivepsychometrictestingmostcommonlyusedfor

evaluations.

Examplesofcognitivepsychometrictestinginclude,butarenotlimitedto:

KaufmanAssessmentBatteryforChildren(KABC):LeiterInternationalPerformanceScale,Stanford-BinetIntelligenceScales(SB),WechslerAdultIntelligenceScale(WAIS),WechslerIntelligenceScaleforChildren(WISC),WechslerPreschoolandPrimaryScaleofIntelligence(WPPSI),Woodcock-JohnsonTestsofCognitiveAbilities(WJCog),

*Version/editionnumbersforeachtestareomittedfromthelisttoaccountfornewlypublishedversions;however,testingdocumentationshouldreflectacurrentversionoreditionofthetestatthetimeitwasadministered.

Alongwiththedescribedprocessforconductingtheformalassessment,theteammustlistexamplesofthetypesofcognitivepsychometrictestingthatwouldbemostcommonlyusedfortheteam'spatientsandtheproviderwhoisresponsibleforinterpretingandreportingresultsfromthesetests.

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Standard6:OutcomesAssessmentTheteamusesaprocesstoevaluateitsownperformancewithregardtopatientassessment,treatment,orsatisfactionandtomakeimprovementsasaresultofthoseevaluations

38. Itisrequiredthattheteamsetupaprocesstoself-monitoritseffectivenessandensure

continualimprovementofoutcomes.Teammeetingsalonedonotmeetthestandard.Doesthe

team(NOTindividualpractitioners)haveaformalprocesstoroutinelyevaluateits

effectiveness/outcomes?

__ Yes

__ No

39. Pleasedescribetheprocess.Ifthereisnoteamprocess,describetheplansfor

implementingoneandincludeatimelineforimplementationwithin12months.

Theprocessdescribedshouldbespecifictotheteamasawholeandnottheinstitutionorindividualteammembers.Examplesincluderegular,systematicassessmentofpatientsatisfactionscores,teamprocessimprovementprojectsandmeetings,regularandsystematicreviewofpatientreportedoutcomes.

40. Describeanexampleofhowtheteamhascollectedanduseddatatochangeteam

processes(e.g.,modifysurgicaltreatment,changereferralcriteria).Thisexamplemaybe

resultoftheprocessoutlineinQuestion39orrelatedtoadifferentprocessusedbytheteam.

Thisexamplecanincludeapublishedstudysuchasamanuscriptorsubmittedabstract.

Theresponseshoulddescribehowthepotentialimprovementisidentified,howtheinterventionisplanned,andhowtheresultisassessed.Whoparticipates?Howistheentireteamkeptinformed?

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Optionally,attachdocumentation(e.g.publishedmanuscript,progressreport,presentation)

supportingtheexampledescribedabove.

Limittheattachmenttofivepages.

41. Describetheteam'squalitymanagementsystemforpatient/familysatisfaction,including

anexampleofhowthisinformationhasbeenusedtoinformchanges(e.g.,improving

patient/familyexperiencesinclinic,communicationwithpatients/familiesbetweenvisits,etc.).

Forexample,patient/familiessurveysconductedbytheteamorreportofaPIproject/narrativedescriptionofaproject.

DigitalSignaturefromTeamLeader/Director

Iftheprimaryuseroftheapplicationisnottheteamleader,theteamleaderwillneedtobeaddedasacollaboratortosignthisform.

Toaddacollaborator,go"Backtoapplication,"click"Addcollaborator"andentertheteamleader'semail.ThisindividualwillreceiveanemailfromSurveyMonkeyApplyinvitingthemtocollaborateontheapplication.

DigitalSignaturefromTeamLeader/DirectorACPATeamApprovalApplicationAgreement

IaffirmthatIhavereadthisapplicationinitsentiretyandconfirmtheaccuracyofalloftheinformationcontainedwithinthisapplication.Iaffirmthatpatientidentifyinginformationhasbeenomittedfromallattachments,thatourTeamabidesbyalloftheinformationprovidedherein,andthatallpatientsreceivingcarefromthisTeamaremanagedeitherbyanappropriateTeammember,soidentifiedinthisapplication,orwithfullknowledgeofthepersonevaluatingortreatingpatientsifreferredtoaprofessionalpersonnotspecificallyidentifiedbynameandprofessionwithinthisapplication.

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SignatureofTeamLeader

Usethecursortodrawyoursignature.

PrintedName

Team Leader Name

SignatureofAuthorizedInstitutionalOfficerInorderfortheAIOtodigitallysigntheform,theywillneedtobeaddedasacollaborator.Toaddacollaborator,go"Backtoapplication,"click"Addcollaborator"andentertheteamleader'semail.ThisindividualwillreceiveanemailfromSurveyMonkeyApplyinvitingthemtocollaborateontheapplication.

Alternatively,youmaychoosetouploadtheAIOsignaturebyclickingUploadForm.Ifyouchoosethisoption,theAIOmustsignthelinkedformwithintheuploadoption.Uploadsthatdonotincludeaformandsignaturewillbeconsideredincomplete.

SignaturefromAIO

*Theadministrativeorganizationmaybeahospital,university,corporation,orself-sponsoredprivatepracticegroup.

**Thepurposeofthisrequirementistodocumentthatsomeonewithfiduciaryresponsibilityfortheinstitution/practiceacknowledgesandsupportstheoperationoftheteamatitsfacility.Thiswouldtypicallybethechiefexecutiveofficer,thechiefmedicalofficer,thedeanofthemedicalschoolorcollege,ortheownerofthepracticeinwhichtheteamoperates.Forthispurpose,adepartmentchairisnottheappropriateperson.

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SignatureofAuthorizedInstitutionalOfficer

Theadministrativeorganization*namedbelowseeksACPATeamApprovalofitsCleftPalate,CraniofacialorCross-SpecialtyTeamandherebyappliesforanevaluationofthisteam.

Thesponsoringorganizationagreestocooperatefullyintheevaluationprocedures,includingfurnishingsuchwritteninformationtotheAmericanCleftPalate-CraniofacialAssociation(ACPA)asshallberequiredforevaluationoftheteam.

ThesponsoringorganizationfurtheragreestosubmitACPA’sTeamSelf-AuditingReportannuallyandagreestopaytheannualfeeforsubmission.ThisreportisrequiredeachyeartoremainanACPAApprovedTeam.

Thisapplicationmaybewithdrawnbytheteamwithoutprejudiceatanytimeandforanyreasonbeforeafinaldecision.

Theadministrativepoliciesofthesponsoringorganizationandtheteammustcomplywithfederal,state,provincial,andlocallaws,regulations,orexecutiveorderswithrespecttoequitabletreatmentofpatientswithoutregardtogender,sexualorientation,age,race,religiouspreference,nationalorigin,ordisablingcondition.

Bycompletingthisform,IconfirmthatIqualifyastheAuthorizedInstitutionalOfficer(AIO)**ofthesponsoringorganizationandthereforeholdfiduciaryresponsibilityfortheinstitution/practice.

PleasenoteyourpreferenceforcompletingtheSignatureofAuthorizedInstitutionalOfficer

Usethecursortodrawyoursignature.

_x_ Electronic Signature

__ Upload

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AdministrativeorSponsoringOrganization*

Institution/OrganizationName ACPA

Address 1504EFranklinStSTe102

City ChapelHill

State/Province NC

PostalCode 27514

Country UnitedStates

AuthorizedInstitutionalOfficer(AIO)**

Name JohnJacobs

JobTitle CEO

Phone 919.933.9044

Email [email protected]

AIOSignature**


acpa team approval: 2020 sample application · orthodontia/pediatric dental. after all patients are...

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