New Activity Application Form

Members of the medical staff at Vernon Jubilee Hospital with hospital privileges can apply for funding support for physician led activities through the Doctors of BC’s Facility Engagement Initiative.

If you are ready to submit a full project proposal please use the form below. Our Program Director will arrange for your proposal to be reviewed by the VJH MSA Executive and Working Group, who may suggest amendments or pass a motion to approve your activity.

(If your project is still an idea and you would like to connect with someone who could help you to make it fly, use our Quick and Easy Project Submission form instead to get things started.)

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Email *

Impact of the

Phone

Activity Name

Expected Time Frame to Complete Project

Total Funding Requested

Name of Other Key Participants

Project Summary (What problem are you trying to solve?)

Objective(s) (What will be improved? What are your expected outcomes?)

Approach/Methodology (How you will accomplish your objectives?)

Identify which of the following MOU objectives are most relevant to this activity.

(Select all that apply)

• To prioritize issues that significantly affect physicians and patient care.
• To improve communication and relationships among the medical staff so that their views are more effectively represented.
• To support medical staff contributions to the development and achievement of health authority plans and initiatives that directly affect physicians.
• To have meaningful interactions between the medical staff and health authority leaders, including physicians in formal Interior Health medical leadership roles.

Evaluation Plan (How will you measure your project’s success? How and when will data be collected and analyzed?)

Paragraph Text

Areas of Impact (Select all that apply)

• ALL
• Acceptability (e.g., decision-making, interpersonal communication)
• Access (e.g., timely access, equitable access, accommodation/barriers)
• Appropriate/Effectiveness (e.g., best practices, scope of practice, unnecessary care)
• Efficiency (e.g., cost avoidance, practice/procedural efficiency)
• Engagement & Collaboration (e.g., physician engagement and leadership, health system collaboration, alignment)
• Quality Improvement (e.g., learning and quality improvement culture, improving existing internal processes, practices, costs or productivity)
• Integration (e.g., care coordination, information sharing, team functioning)
• Safety (e.g., adverse events, infection prevention/control)
• Spread & Sustainability
• N/A

Facility Impact (List the facility areas that the activity would impact (e.g. medical areas, departments, health authority operational areas)

Interior Health Engagement (Any proposed activity involving patient care, flow, environment, data analytics, allied health, or resources would benefit from early consultation with IH.)

• I need help finding the appropriate HA partners
• My collaborative HA partners/dyads are:

Budget Provide details including proposed physician sessional hours, the rate is $176.18 per hour.)

• I need help with figuring out a budget.

Special Provisions (Are there any regulatory requirements, ethical considerations, or legal ramifications that should be considered?)

Milestones (Indicate significant achievements during the timeline of the activity and approximate dates they will be achieved)

Agreement

• I agree to submit quarterly reports (online form available) to update on my project status.
• I understand that funding for this project is only available for 12 months after approval.
• I have received written approval from my Department Head for this work.
• I agree to do a brief presentation to the VJHPS Working Group upon completion of my project.

Submit