Registration Form - Innovator Homes

Thank you for your interest in becoming an Innovator Home!

Each home will be expected to complete the following requirements.

Establish a Med Safety Team (if not already in place), including engagement of resident and family members.
Ensure that at least one member of the Med Safety Team attends the free mini-workshops and webinars throughout the 6-month period. Additional home participants are encouraged.
Complete free self-assessments (including the Medication Safety Self-Assessment for Long-Term Care as well as Resident and Family engagement feedback) to help identify medication safety opportunities for improvement.
Compile and submit Medication Safety Indicator reports quarterly.
Facilitate monthly Med Safety Team meetings at the home to advance the learn, share and act activities within the initiative.
Implement a QI project to improve medication safety.

It is anticipated that the Med Safety Team Leader will spend approximately 2 hours each week coordinating or completing this work for the home.

Please complete the registration form below and further information will be provided to you.

Contact LTC@ismpcanada.ca with any questions.

Name of Long-Term Care Home(Required)

Home Address(Required)

Number of Residents in the Home(Required)

Name of Team Lead for the Innovator Home initiative(Required)

Team Lead Position/Title(Required)

Phone # and Extension(Required)

E-mail address(Required)

Administrator Name(Required)

Administrator e-mail address(Required)

Director of Care Name(Required)

Director of Care e-mail address(Required)

Medical Director Name(Required)

Medical Director e-mail address(Required)

Pharmacist Lead for the initiative(Required)

Pharmacist Lead e-mail address(Required)

Is the Home located in a rural and/or northern location?(Required)

Yes

Authorization to Participate(Required)

Innovator Homes are asked to submit Medication Safety Indicator Data and topic specific self-assessment results to ISMP Canada for analysis. De-identified findings are shared for quality improvement actions.

The Administrator, Director of Care and Medical Director are supportive of this registration as an Innovator Home.

Yes

Allow Home Name to be Shared Publicly

The name of the Home can be shared publicly on the ISMP Canada website.

Yes

Name of person completing the registration form(Required)

Title of person completing the registration form(Required)