Health Equity Collaborative Enrollment Form

Washington State Hospital Association invites you to enroll your hospital or health system in the Health Equity Collaborative. By completing this enrollment form, your organization commits to participate in the 18-month collaborative focusing on implementing fundamental components of health equity in the following three domains: 1) Leadership and culture of equity 2) Data, analytics and quality improvement 3) Addressing social determinants of health Thank you for your interest and dedication to improving the health of the communities you serve.

Select Hospital(s)*

You may select multiple hospitals if more then one facility within a health system is participating in the collaborative.

Select

Identify Team Members

The Health Equity Collaborative requires participating hospitals and health systems to form action teams to design and test improvement projects. Please identify primary team members and an executive sponsor who will have primary responsibility for implementation.

Team Lead

Primary contact for health equity communications, will lead team planning, implementation and ensure reporting is completed.

Team Lead*

Job Title (Team Lead)*

Email (Team Lead)*

Phone Number (Team Lead)*

Executive Sponsor

Provides administrative support and dedicated resources to insure protected time and resources for the implementation team.

Executive Sponsor*

Email (Executive Sponsor)*

Data Analyst

The data analyst has access to your internal data systems(EHR/EMR) and understands how data is captured, stored and retrieved.

Data Analyst*

Email (Data Analyst)*

Additional Team Members

This work is best accomplished through collaboration across a multi-disciplinary team. Suggested team members include social workers, discharge nurses, physician champions, health equity officers, patient experience professionals, registration staff, interpretive services and patient advocates. You may add to your team at any time. To add additional team members now, please follow this link to complete the form: https://app.smartsheet.com/b/form/c795486a6f6848dbab1a4731732ea691

Participation Agreement

To fully participate in the Health Equity Collaborative , please review and indicate your agreement with the following responsibilities:

1. Take Action:*

Commit to implementing health equity projects in all three domains (Leadership/Culture, Data/Analytics, Social Determinants of Health) over an 18-month period.

2. Include Patient Voice:*

Develop a strategy for including patients in the co-design and evaluation of quality improvement projects.

3. Determine Data Readiness:*

Explore capacity of technical team to make changes to systems, understand how patient demographic data is stored and retrieved, and if using a shared EHR enterprise license, engage sponsoring health system.

4. Engage in Collective Learning:*

Contribute to the “all teach, all learn model” by sharing your experiences, successes and failures. Be open to feedback from others and proactively reach out for help.

5. Report Progress:*

Complete monthly/quarterly data reporting (engagement, progress on action plans), as well as the pre/post Health Equity Gap Assessment.

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