Georgia Chapter Firearm Injury Prevention Quality Improvement
Project Enrollment Request Form

Introduction

Thank you for your interest the Georgia Chapter of the American Academy of Pediatrics Firearm Injury Prevention Quality Improvement Project. This project will use the Plan Do Study Act process to achieve practice transformation. An application to the ABP will be submitted for MOC Part 4 and MOC Part 2 credits.

Enrollment consideration will be based:

Practice Team participation in our Aug, 26th virtual Symposium.
Practice benchmark data on 4 data measures from twenty 3-year-old visit charts by Aug. 18th
Physician Leader participation in monthly technical assistance calls with a Project Leader.
Data Manager monthly submission from ten 3-year-old visit charts between Sept. 2023 - Feb. 2024.

We look forward to reviewing your application for this complimentary educational opportunity. Thank you for completing this short application.

Question Title

* 1. How many physicians from your practice will be participating in this project?

2-3

4 or more

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* 2. Please indicate where your practice is located:

Urban (Metro Atlanta)

Rural (Outside Metro Atlanta)

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* 3. Please rate your practice knowledge of the following:

	Poor	Not so Good	Good	Very Good	Excellent
Quality Improvement to Achieve Practice Transformation	Quality Improvement to Achieve Practice Transformation Poor	Quality Improvement to Achieve Practice Transformation Not so Good	Quality Improvement to Achieve Practice Transformation Good	Quality Improvement to Achieve Practice Transformation Very Good	Quality Improvement to Achieve Practice Transformation Excellent
Completion of a Plan Do Study, Act Worksheet	Completion of a Plan Do Study, Act Worksheet Poor	Completion of a Plan Do Study, Act Worksheet Not so Good	Completion of a Plan Do Study, Act Worksheet Good	Completion of a Plan Do Study, Act Worksheet Very Good	Completion of a Plan Do Study, Act Worksheet Excellent
Ability to pull documentation on anticipatory guidance from your patient's electronic health record.	Ability to pull documentation on anticipatory guidance from your patient's electronic health record. Poor	Ability to pull documentation on anticipatory guidance from your patient's electronic health record. Not so Good	Ability to pull documentation on anticipatory guidance from your patient's electronic health record. Good	Ability to pull documentation on anticipatory guidance from your patient's electronic health record. Very Good	Ability to pull documentation on anticipatory guidance from your patient's electronic health record. Excellent

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* 4. Please provide the following practice information:

Practice Name

Address

Phone Number

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* 5. Please list the following for your Practice Physician Lead

Name

Best Email

Best Phone Number

Question Title

* 6. Please provide the following for your Practice Data Manager:

Name

Best Email

Best Phone Number

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* 7. By participating in this project, the Practice Physician Lead and the Practice Data Manager agree to participate in the Virtual Firearm Injury Prevention Symposium on Saturday, August 26, 2023.

Agree

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* 8. Benchmark data from 20 three-year-old well visit charts is due by August 18, 2023.

I understand

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* 9. Active participation is required; Practice Physician Leads are expected to participate in monthly technical assistance calls and provide data on 10 three-year-old well visit charts between September 2023 - February 2024.

I understand

Georgia Chapter Firearm Injury Prevention Quality Improvement Project Enrollment Request Form

Introduction

Question Title

* 1. How many physicians from your practice will be participating in this project?

Question Title

* 2. Please indicate where your practice is located:

Question Title

* 3. Please rate your practice knowledge of the following:

Question Title

* 4. Please provide the following practice information:

Question Title

* 5. Please list the following for your Practice Physician Lead

Question Title

* 6. Please provide the following for your Practice Data Manager:

Question Title

* 7. By participating in this project, the Practice Physician Lead and the Practice Data Manager agree to participate in the Virtual Firearm Injury Prevention Symposium on Saturday, August 26, 2023.

Question Title

* 8. Benchmark data from 20 three-year-old well visit charts is due by August 18, 2023.

Question Title

* 9. Active participation is required; Practice Physician Leads are expected to participate in monthly technical assistance calls and provide data on 10 three-year-old well visit charts between September 2023 - February 2024.

Georgia Chapter Firearm Injury Prevention Quality Improvement
Project Enrollment Request Form