Expression of Commitment INSPIRED Approaches to COPD: Improving Care and Creating This Expression of Commitment constitutes a team application to participate in the Canadian Foundation for Healthcare Improvement (CFHI) and Boehringer Ingelheim (Canada) Ltd. (BICL) quality improvement collaborative focused on implementing a proven approach to chronic obstructive pulmonary disease (COPD) care – the INSPIRED (Implementing a Novel and Supportive Program of Individualized care for patients and families living with REspiratory Disease) COPD Outreach Program. Please refer to the INSPIRED Approaches to COPD: Improving Care and Creating Value Prospectus for detailed information before filling out this application form. Please Note The deadline for submission of the Expression of Commitment is June 30, 2014 and participants will be notified of decision by July 18, 2014. Teams will be selected by CFHI faculty and staff based on the strength of their alignment with requirements described within the Prospectus and CFHI considerations of overall composition of the cohort of teams in terms of diversity of setting and context. CFHI to limit enrolment in the quality improvement collaborative to approximately 10 organizations. By completing the application form, the organization and team members confirm that they understand , including rules regarding eligibility of foundation employees, trustees and agents. Expressions of Commitment must fully disclose any relationship with the current members of the . Organizations from which any members of the CFHI Board of Trustees, or foundation agents or employees receive remuneration are eligible to apply to this competition. All applicants will receive summary feedback from the reviewers. Application Instructions Please submit, by , your completed Expression of Commitment (in PDF and MS Word format) and: Abbreviated curriculum vitae (CV one-pager) for each team member. Declaration of any potential conflict of interest as per CFHI’s policy. The maximum page limit for Sections A to C of the expression of commitment is 7 pages. All applications must be on letter-sized paper (8 ½ x 11), single space, with use of the margins and Calibri 11-point font that have been preset into the form. Assessment Criteria A summary of criteria against which applicants will be assessed is available upon request. Questions and completed applications should be directed to Meghan Rossiter, Improvement Liaison, at . A: Organizational Commitment Organizational Commitment – must be made by the CEO or person of highest accountability in the organization (e.g. accountable to the board of directors)
Telephone Fax E-mail Original Signature CV one-pager attached Yes □ Language of Correspondence English □ French □ Administrative Lead Mr./Mrs./Ms./Dr. Name Title/Department Organization Mailing Address City Province Postal Code Telephone Fax E-mail Original Signature CV attached Yes □ Language of Correspondence English □ French □ Project Lead (overall project team lead for all communications with CFHI) Mr./Mrs./Ms./Dr. Name Title/Department Organization Mailing Address City Province Postal Code Telephone Fax E-mail Original Signature CV one-pager attached Yes □ Language of Correspondence English □ French □ Evaluation and Measurement Lead Mr./Mrs./Ms./Dr. Name Title/Department Organization Mailing Address City Province Postal Code Telephone Fax E-mail Original Signature CV one-pager attached Yes □ Language of Correspondence English □ French □ Physician Champion
Mailing Address City Province Postal Code Phone Preferred Language Email Health Discipline Role on the Team Experience Relevant to this Initiative APPENDIX 1: Eligible and Ineligible budget expenses CATEGORY ELIGIBLE INELIGIBLE** Personnel (up to 100% of eligible expenses)* release time for team members whose regular job description will be amended to allow them to work on the quality improvement initiative funds to hire additional staff to backfill the jobs of team members who are being released to work on the quality improvement initiative salary replacement costs to allow providers to participate in the quality improvement initiative (not including delivery of services) eligible release time charged at rates above existing salary service delivery costs release time related to the financial administration of collaborative funds