Registration Form - AUA Innovator Network

Thank you for your interest in joining the Ontario AUA Innovator Network!

Each Home is asked 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 8-month period. Additional home participants are encouraged.
Complete an AUA self-assessment.
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.
Complete the registration form by August 31, 2025.
Join the launch webinar in September 2025 and participate in monthly AUA sharing and learning webinars where participants will share their insights into successfully advancing AUA locally!

It is anticipated that the Med Safety Team Leader at each Home will participate and facilitate work on this initiative approximately 2 hours each week.

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)

Participants of the Ontario AUA Innovator Network are asked to submit Medication Safety Indicator Data and topic specific self-assessment results through a secure online portal 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 a member of the AUA Innovator Network

Yes

Allow Home Name to be Shared Publicly

Do you agree to the name of your Home being shared on the ISMP Canada website as a participant in the Ontario AUA Network?

Yes

Name of person completing the registration form(Required)

Title of person completing the registration form(Required)