Which unit(s) provided care for you or your family member: (check all that apply) [Insert name of unit] [Insert name of unit] [Insert name of unit] [Insert name of unit] We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor? (Check one) Less than 1 hour per month 3 to 4 hours per month 1 to 2 hours per month More than 4 per month Are you available to serve as an advisor for at least 1 to 2 years? (You can still be an advisor if you answer “no.”) Yes No How do you want to help? I want to: (Check all of your interest areas) [NOTE: Edit the list below as appropriate for your hospital’s priorities] Serve as a member of the patient and family Review procedures and provide input to improve the advisory council. Potential advisory council hospital admission process. members should be ready to commit to Provide input as we implement bedside shift report, serving on the council for at least 1 to 2 where nurses who are going off duty share years. The advisory council meets once a information with nurses coming on duty at the month for 1 ½ to 2 hours. patient’s bedside. Help develop or review informational Review procedures and provide input to improve materials for patients and family members. transitions in care (for example, between hospital Help improve patient safety and the units or discharge from hospital to home). prevention of medical errors. Other issues (please describe): Help improve the patient and family role in care decisionmaking. . Help improve the hospital facilities (for example, patient care areas, or family . resource room). . Help educate or hospital staff and clinicians.
Which unit(s) provided care for you or your family member: (check all that apply) [Insert name of unit] [Insert name of unit] [Insert name of unit] [Insert name of unit] We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor? (Check one) Less than 1 hour per month 1 to 2 hours per month 3 to 4 hours per month More than 4 per month Are you available to serve as an advisor for at least 1 to 2 years? (You can still be an advisor if you answer “no.”) Yes No How do you want to help? I want to: (Check all of your interest areas) [NOTE: Edit the list below as appropriate for your hospital’s priorities] Serve as a member of the patient and family advisory council. Potential advisory council members should be ready to commit to serving on the council for at least 1 to 2 years. The advisory council meets once a month for 1 ½ to 2 hours. Help develop or review informational materials for patients and family members. Help improve patient safety and the prevention of medical errors. Help improve the patient and family role in care decisionmaking. Help improve the hospital facilities (for example, patient care areas, or family resource room). Help educate or hospital staff and clinicians. Review procedures and provide input to improve the hospital admission process. Provide input as we implement bedside shift report, where nurses who are going off duty share information with nurses coming on duty at the patient’s bedside. Review procedures and provide input to improve transitions in care (for example, between hospital units or discharge from hospital to home). Other issues (please describe): . . .
AHRQPFEGuidePatientFamilyApplicationForm.docx