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ACPA TEAM APPROVAL:
2020 SAMPLE APPLICATION
Standard1:TeamComposition
TeamInformationUponapproval,fieldswillbeusedfortheofficialteamlisting*
TeamID
IfyoudonotknowyourteamID,[email protected].
99999
ApplicationType
Cross-SpecialtyTeam(bothcleftpalateandcraniofacial)
1. TeamListingInformation
NameofTeamandInstitution*
TeamACPA
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TeamAddress
CompanyName ACPA
Street* 1504EFranklinStSte102
City* ChapelHill
State/Province* NC
Zip/PostalCode* 27514
Country* UnitedStates
PrimaryEmail [email protected]
PrimaryPhoneNumber 919.933.9044
PrimaryFaxNumber (Noresponse)
TeamWebSite
www.acpa-cpf.org
PatientAgeRangeFrom*
0
PatientAgeRangeTo*
99
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LeadTeamMembers
2. TeamCoordinator(s)
Theteamincludesadesignatedpatientcarecoordinatortofacilitatethefunctionandefficiencyoftheteam,ensuretheprovisionofcoordinatedcareforpatientsandfamilies/caregiversandassisttheminunderstanding,coordinatingandimplementingtreatmentplans.
TeamCoordinator1
FirstName* Erin
LastName* Mallis
Designations(i.e.MD,DMD,PhD)* N/A
Specialty* Coordinator/Administrator
Email* [email protected]
Addanothercoordinator
3. Describethespecificrolesandresponsibilitiesoftheteamcoordinator(s)andhowthey
ensurecoordinatedcare.
Therolesandresponsibilitiesoftheteamcoordinatorshouldincludehowtheyinteractwithpatients/familiesandmembersoftheteam.
4. TeamLeader/Director
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TeamLeader/Director1
FirstName* Alyssa
LastName* Kirkman
Designations(i.e.MD,DMD,PhD)* N/A
Specialty* Coordinator/Administrator
Email* [email protected]
Addanotherleader
5. CraniofacialTeamLeader(mustbetrainedintranscranialsurgery)
Thecraniofacialteammustincludeasurgeontrainedintranscranialcranio-maxillofacialsurgery.
FirstName* Mark
LastName* Johnson
Designations(i.e.MD,DMD,PhD)* MD
Specialty* CraniofacialPlasticSurgery
EmailAddress (Noresponse)
6. Describethebackground/educationalandtrainingqualificationsoftheteam’scraniofacial
surgeon.
Example:MarkJohnsonreceivexxtrainingatABCHospitalandxxtrainingatXYZMedicalCenter.
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7. RegularTeamMembers
Allregularlyparticipatingteammembersshouldbelistedinthissection.
Theteammustincludespeech-languagepathology,surgical,andorthodontic
specialties.Pleaselistthesecoreteammembersfirst.
RegularTeamMember1
FirstName* John
LastName* Smith
Designations(i.e.MD,DMD,PhD)* MD
Specialty* PlasticSurgery
EmailAddress (Noresponse)
Addanothermember
RegularTeamMember2
FirstName* Jane
LastName* Doe
Designations(i.e.MD,DMD,PhD)* MA
Specialty* Speech-LanguagePathology
EmailAddress (Noresponse)
Addanothermember
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RegularTeamMember3
FirstName* William
LastName* Williams
Designations(i.e.MD,DMD,PhD)* DMD
Specialty* Orthodontics
EmailAddress (Noresponse)
Addanothermember
Regular Team Member 4
FirstName* Harry
LastName* James
MD
Specialty* Otolaryngology
Designations(i.e.MD,DMD,PhD)*
EmailAddress
Addanothermember
(Noresponse)
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8. ListindividualsthattheteamworkswithonareferralbasisthatareNOTregularteam
members.
Theteammustdemonstrateaccesstoprofessionalsinthedisciplinesofpsychology,social
work,audiology,genetics,dentistry,otolaryngology,andpediatrics/primarycare.
Craniofacial/Cross-Specialtyteamsmustalsodemonstrateaccesstoprofessionalsinthe
disciplinesofneurosurgery,ophthalmology,andradiology.
Ifanyoftheabovespecialtiesareregularteammembers,listthemintheRegularTeamMemberssectiononthepreviouspage.
Doesyourteamhaveaccesstootherprofessionalswhoarenotregularteammembers?*
Yes
Regular Team Member 5
FirstName* Martin
LastName* Thomas
MD
Specialty* Pediatrics/PrimaryCare
Addanotherprofessional
Designations(i.e.MD,DMD,PhD)*
EmailAddress (Noresponse)
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OtherProfessional2*
FirstName* Mary
LastName* Thompson
Institution/Practice* ABC
Designations* LSW
Specialty* SocialWork
Addanotherprofessional
OtherProfessional1*
FirstName* Joe
LastName* Sample
Institution/Practice* ZZZ
Designations* PhD
Specialty* Psychology
Addanotherprofessional
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OtherProfessional4*
FirstName* Jim
LastName* Example
Institution/Practice* XYZ
Designations* MD
Specialty* Genetics
Addanotherprofessional
OtherProfessional3*
FirstName* Sarah
LastName* Jones
Institution/Practice* ABC
Designations* AuD
Specialty* Audiology
Addanotherprofessional
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OtherProfessional6*
FirstName* Tom
LastName* Daniels
Institution/Practice* ABC
Designations* MD
Specialty* Neurosurgery
Addanotherprofessional
OtherProfessional5*
FirstName* Lisa
LastName* Test
Institution/Practice* XDentalPractice
Designations* DDS
Specialty* PediatricDentistry
Addanotherprofessional
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OtherProfessional7*
FirstName* Emily
LastName* Jacobs
Institution/Practice* XYZ
Designations* MD
Specialty* (Noresponse)
Addanotherprofessional
OtherProfessional8*
FirstName* Bill
LastName* Morris
Institution/Practice* XYZ
Designations* RT
Specialty* Radiology
Addanotherprofessional
Standard2:TeamManagementandResponsibilitiesResponses should describe normal team processes outside of any temporary changes due to COVID-19.
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Theteamhasamechanismforregularmeetingsamongcoreteammemberstoprovidecoordinationandcollaborationonpatientcare.
Note:
Teammeetingsrefertomeetingsamongmultidisciplinaryteammembersinwhichpatientfindingsarediscussedandteamrecommendationsaremade.Ataminimum,teammeetingsmustincludethespeech-languagepathologist,surgeon,andorthodontist.
Teamorpatientevaluationisthepatient-facingcomponentoftheteam'sprocess,inwhichpatientsreceiveface-to-faceevaluationbythedisciplinesrepresentedontheteam.
9. Howoftenareteammeetingsheld?
__ Quarterly
__ Monthly
__ Bi-weekly
__ Weekly
__ Other, please specify...: Team meetings should be frequent enough that the participants are able to remember
the evaluations for the patients discussed.
10. Inwhatformatareteammeetingsheld?
__ Face-to-face
__ Not face-to-face but in real time (e.g. conference call)
__ Neither
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Explainhowtheteamensuresallpatientsarediscussedcollaborativelyamongatminimumthe
coreteammembers(speech-languagepathologist,surgeon,andorthodontist).
Ataminimum,thecoreteammembersshoulddiscusseachpatientandformulateamultidisciplinarytreatmentplan.Ifthisdoesnothappeninrealtime,eitherinpersonorusingelectronicmodalities,theteammustjustifyhowitsmethodensuresthatthereisdialogamongthosespecialties.Simplereportingoffindings/recommendationsindividuallythroughacentralchartorthroughacoordinatorisnotcompliant.
11. Areteammeetingsheldthesamedayasthepatientevaluation?
__ Yes
__ No
Howdoestheteamensurethatpatientinformationisnotforgottenormissed?
Example:Theteamcoordinatoremailsthelistofpatientstobediscussed2dayspriortotheteammeeting.EachparticipanthasaccesstotheirnotesviatheEMRandisresponsibleforreferringtothosenotesduringtheteammeetingwhengivingtheirreport.Theteammeetingreportisthensenttoallparticipants,whoareresponsibleforreviewingthereportandattestingthattheyagreewiththecontent.
12. Doesthepatienthavetheopportunitytoreceivesame-dayface-to-faceevaluationbyall
coreteammembers(speech-languagepathologist,surgeon,andorthodontist)?
__ Yes
__ No
This question will only be shown if you indicate Neither in the previous question.
This question will only be shown if you indicate No in the previous question.
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Describehowtheteamensuresthatmultidisciplinaryteamevaluationlinkedto
multidisciplinaryteamreportingoccurs.
Ifface-to-faceevaluationsdonotoccursame-day,theteammustindicatehowtheteamensurespatientsreceivemultidisciplinaryevaluations,integratingfindingsandrecommendationsfromalldisciplines.Evaluationsshouldbewithinacloseenoughtimeframethatitisclearthatallthreeprofessionalsareevaluatingthepatientatthesamestage.
Example:ThecoordinatorassignsappointmentsforthepatientfortheSLP,surgeryandorthodontiawithinthesame30dayperiod,anddoesaphoneassessmentifappointmentsforanyotherteamspecialistsareindicated.
13. Describetheprocedureusedbytheteamifoneormoreoftheusualcoreteammembers
cannotattendateammeeting.
Example:Doessomeonesubstituteinthisprovider'splace?Isthemeetingrescheduled?
14. Describehowapatientreceivescomprehensivesame-dayface-to-facemultidisciplinary
evaluation.Includedescriptionofatypicalteamevaluationofpatientsandhowthisleadsto
integrateddecisionmaking.
Describetheproceduresofatypicalteamevaluationandhowtheteammemberscollaborateduringtheevaluationandafterwardstomakedecisionsandformulaterecommendationsinamultidisciplinarymanner.
Example:Frombirthtoage8,allpatientsreceiveafullteamevaluationyearly.Patientsreceiveapsychosocialscreening,pediatricscreening,andassessmentsbySurgery,SLP,ENT,Audiology,andOrthodontia/pediatricdental.Afterallpatientsareseen,theteammeetstodiscusseachpatientandreachateammultidisciplinaryrecommendation.Afterage8,intervalsoffullteamevaluationaredeterminedbyneedanddiagnosis.Patientsalsoseeindividualspecialistsasneeded.
This question will only be shown if you indicate No in the previous question.
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15. Describehowtheresultsoftheteammeetingforeachindividualpatientarerecordedand
becomeapartofthepatient’steamreport.
Whoisresponsibleforrecordinginformationfromthemeeting?Wheredoesthisinformationgetrecorded?
Example:Duringtheteammeeting,eachpatient’sfindingsarediscussedbythepertinentspecialist,andthentheentireteamdiscussesandagreesonrecommendations.Notesaretakenbytheteamcoordinator.Ateamreportisauthoredbytheteamleader.ThereportisanEMRtemplatethatincludeseachspecialistfindingsasimportedfromtheindividualreportsintheEMR,andrecommendationsgeneratedafterteamdiscussion.ThereportissavedasamultidisciplinaryteamreportintheEMR.ThecoordinatorisresponsibletoprovidethereporttothefamilyandthePrimaryCareProvider.
16. Uploadpagesfromonepatientteamreportthatdocumentstheparticipationofthe
speech-languagepathologist,surgeonandorthodontist.Iftheteamisacraniofacialorcross-
specialtyteam,thereportshouldalsodocumenttheparticipationofthetranscranialsurgeon.
Ateamreportmustbeasingledocumentthatidentifies:
Theconditionbeingtreated,specialtiesinvolved,andyearoftheevaluation.Redactthemonthanddayofevaluation.Thefindingsforeachspecialtyevaluationandspecificteamrecommendations.Theyearofteammeetingthatgeneratedthereportandtheindividuals(withspecialty)whoparticipatedintheteammeeting.Thepersonwhohasgeneratedtheteamreport.
Placeastarbythesection(s)ontheattachmentsthatdocumentcompliancewiththestandard.Omitidentifyinginformationandlimittheattachmenttofivepages.
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Theteamhasamechanismforreferraltoandcommunicationwithotherprofessionals.
17. Describetheprocessforinformationexchangewithschools,primarycareprofessionals,
outsideagencies,andotherprofessionalsinvolvedwiththewelfareofthepatient.
Describetheprocessforinformationexchange(i.e.referrals)foroutsideinstitutions,notinternalteammembers.BesuretocommentonbothcommunicatingwithANDreceivinginformationfromotherentities.
Example:Atthetimeofteamevaluation,consentforreleaseofrecordsisobtained,andthefamilymayindicaterecipientsfortheteamevaluation.Iftheteammeetingrevealsaneedforrecordsrequest,thecoordinatorcontactstheappropriateprovider/organization,providesthesignedrelease,andobtainstherecord,whichisscannedintotheEMR.Familiesareprovidedwithacopyofeachteamreport,whichtheyareencouragedtosharewithotherspecialistsandagenciesasneeded;additionally,theteamreportissentelectronicallytothepatient’sPCPifoneisdesignatedintheEMR.
18.UploadacopyoftheReleaseofInformationFormusedbytheteam.Thisformshouldbe
blank.Limittheattachmenttotwopages.
19. Describehowtheteamfacilitatesthetransitiontoadultcareifnotallprovidersonthe
teamtreatpatientsafterage18or21.
Arepatientsreferredelsewhere?Dopatients/familiesreceiveinformation/resources?
Example:Atage12,planningfortransitionforadultcarebeginswithdiscussionwithfamily.Atappropriateages,familiesareprovidedwithrecommendationsforprovidersforadultprimarycareandadultdentalcare.Oursurgical,orthodontic,SLPandENTprovidersprovideadultcareaswell.Resourcesforspecialneedspatientsaresuggested.Patientsaretransitionedoutofteamcarebyage21,howeverteamresourcesremainavailableasneeded.
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Theteamre-evaluatespatientsbasedonteamrecommendations.
20. Describetheprotocolforhowtheteamevaluatesapatientwithcleftlip/palateovertime
(E.g.,developmentalmarkers,age,etc.).Includewhichteammembersseepatientsatwhich
points,includingcoredisciplines(surgery,speech,andorthodontics)andreferrals.
Includeatminimumthecoreteammembersandatwhichtimepointstheyevaluatepatientswithcleftlip/palate.Includespecifictimepoints(e.g.,agesorfrequency)atwhichpatientsareseenbyorreferredtonon-coredisciplines,ifdifferentfromcoredisciplineevaluationschedule.
Example:PatientswithCL/Pareevaluatedbythefullteamyearlytillbonegraft,thenatminimumevery2years,ormorefrequentlyifneeded,untilcompletionoftreatment.
21. Provideanexampleofacraniofacialdiagnosistreatedbytheteamanddescribethe
protocolforhowtheteamevaluatesapatientwiththisdiagnosisovertime(E.g.,
developmentalmarkers,age,etc.).Includewhichteammembersseepatientsatwhichpoints,
includingcoredisciplines(surgery,speech,andorthodontics),thecraniofacialsurgeon,and
referrals.
Includeatminimumthecoreteammembersandcraniofacialsurgeonandatwhichtimepointstheyevaluatepatientswithacraniofacialdiagnosis.Includespecifictimepoints(e.g.,agesorfrequency)atwhichpatientsareseenbyorreferredtonon-coredisciplines,ifdifferentfromcoredisciplineevaluationschedule.
Theteammusthavecentralandsharedrecords.
22. Doestheteamuseastandardizedelectronicmedicalrecordforstorageofnotesand
reports?
__ Yes
__ No
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Describethemechanismsforrecord-keeping(e.g.,wherehousedandmaintained,accessto
records,etc.)
Theteamshouldhaveamechanismforkeepingrecordsthatallteammembershaveaccessto.
23. Describehowrecommendationsbecomepartofthepatientrecordwhenpatientsare
evaluatedoutsideoftheteamsetting.
Example:Theteamrequestsacopyofthereportfromrelevantevaluationsconductedoutsideoftheteamsetting.Thisreportisscannedintothepatient'smedicalrecord,andrelevantfindingsandrecommendationsareincludedinthepatientabstractsdraftedforteamprovidersaheadofeachteamclinicandaresummarizedinthepatient'snextteamreport.
Standard3:PatientandFamily/CaregiverCommunicationTheteamprovidesappropriateinformationtothepatientandfamily/caregiveraboutevaluationandtreatmentproceduresorallyandinwriting.
24. Whoisresponsibleforprovidinginformationaboutpatientevaluationandthe
recommendedtreatmentstofamiliesandpatients?Howistheinformationcommunicatedto
thembothorallyandinwriting?
Indicatetheindividualwhoisresponsibleforprovidinginformation.Includehowinformationisprovidedbothorallyandinwriting.
Theteamencouragespatientandfamily/caregiverparticipationinthetreatmentprocess.
This question will only be shown if you indicate No in the previous question.
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25. Describehowthefamily/caregiverhasopportunitiestoplayanactiveroleinthedecision-
makingprocessforthetreatmentplan.
Theteamshouldindicatehowthefamily/caregiverisinvolvedindecision-making.
26. Describehowthepatientisinvolvedinthedecision-makingprocessforthetreatmentplan
atanappropriateage.
Theteamshouldindicatehowthepatientisinvolvedindecision-making.
Theteamwillassistfamilies/caregiversinlocatingresourcesforfinancialassistancenecessarytomeettheneedsofeachpatient.
27. Describetheprocessforinformingfamilies/caregiversoffinancialandinsurance-related
resources.Thesemightincludefederal,state,andprovincialregulationsspecificallygoverning
thetreatmentofcleft/craniofacialanomalies.(e.g.,insurance,stateagencies,PublicLaw94-
142,504s,andindividualizededucationalplans).
Provideexamplesoffinancialresourcesprovidedtofamilies.
Standard4:CulturalCompetenceTheteamdemonstratessensitivitytoindividualdifferencesthataffectthedynamicrelationshipbetweentheteamandthepatientandfamily/caregiver.
28. Howdoestheteamcommunicatewithpatientsandfamiliesforwhomtheteam'slanguage
isnottheirprimarylanguage?Doestheteamuseinterpretersortranslatedmaterials?
Indicatehowtheteamcommunicatesbothorallyandinwriting.
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29. Howdoestheteamensurethatitissensitivetoethnicandculturaldiversity?Describeany
training,education,orinterventionsthatareusedbeyondhavingbilingualstaff.Trainings
requiredbytheteam'sinstitutionaswellaseducationprovidedwithintheteamare
acceptabletoinclude.
Forexample,thismaybeanannualmandatoryinstitutionalculturalsensitivityanddiversitytraining.
Theteamtreatspatientsandfamilies/caregiversinanon-discriminatorymanner.
30. Howdoestheteaminformpatientsandfamilies/caregiversoftheirrights(e.g.,patientbill
ofrights,Website,institutionalliterature,etc.)?
Aretheyprovidedmaterials,referredtothewebsite,etc?
31. ProvidealinktoorattachacopyofthePatient'sBillofRights.Aprivacypolicydoesnot
qualify.Limitattachmenttothreepages
PleasedenotehowyouwillattachthePatient'sBillofRights
_x_ Link to website
__ Upload
Pleaseattachthecompletewebaddress
http://www.acpa-cpf.org
Standard5:PsychologicalandSocialServicesTheteamhasamechanismtoinitiallyandperiodicallyassessandtreat,asappropriate,thepsychologicalandsocialneedsofpatientsandfamilies/caregiversandtoreferforfurthertreatment,asnecessary.
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32. Describehowtheteamidentifiesandreferspatientsandfamilies/caregiverswhomaybein
needoffurtherevaluationandtreatmentforemotionalorbehavioralissues.Includethe
team'sprocessforidentifyingtheseissuesandthespecificteammember(s)responsiblefor
implementingtheprocess.
Theteamshouldindicatewhichteammemberisresponsibleforidentifyingemotionalorbehavioralissuesandtheirqualifications.Includeanyscreeningtoolsusedtoidentifyandreferpatientsandfamilies/caregiversinneedoffurtherevaluationandtreatment.Astatementthatallteammembersmayidentifyandrecommendevaluationforpsychosocialissuesisnotsufficient.Thereshouldbeanidentifiedindividualwhoscreensforthisinaregularandsystematicmanner.
Example:Theteam'spsychologistmeetswithpatientsandfamiliesaspartofeachteamevaluationandperformsabriefpsychosocialinterviewtoscreenforconcerns.
33. Doesamentalhealthproviderlistedasaregularteammemberevaluate/treat
emotional/behavioralissues?
__ Yes
__ No
Whomdoestheteamreferpatientsandfamilies/caregiverstoforfurtherevaluationand
treatmentofemotionalorbehavioralissues?Includetheindividual'squalifications.
ThisindividualshouldbelistedinStandard1-AccesstoOtherProfessionals.
Theteamhasamechanismtoassesscognitivedevelopment.
This question will only be shown if you indicate No in the previous question.
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34. Describehowtheteamidentifiespatientswhomaybeinneedoffurtherevaluationor
treatmentforcognitivedevelopmentissues(e.g.,learningdisabilities).Includetheteam's
processforidentifyingtheseissuesandtheteammember(s)responsibleforimplementingthe
process.
Theteamshouldindicatewhichteammemberisresponsibleforidentifyingcognitivedevelopmentissuesandtheirqualifications.Includeanyscreeningtoolsusedtoidentifyandreferpatientsandfamilies/caregiversinneedoffurtherevaluationandtreatment.Astatementthatallteammembersmayidentifyandrecommendevaluationforcognitiveissuesisnotsufficient.Thereshouldbeanidentifiedindividualwhoscreensforthisinaregularandsystematicmanner.
Example:Thenursecollectstheeducationalhistory,andtheSLPandpediatricianscreenfordevelopmentalissues.ThecoordinatorisresponsibleforfollowupofrecommendationsforChildStudyteam,EarlyIntervention,orDevelopmentalPediatricsevaluations.
35. Doesamentalhealthproviderlistedasaregularteammemberevaluate/treatcognitive
developmentissues?
__ Yes
__ No
Whomdoestheteamreferpatientsandfamilies/caregiverstoforfurtherevaluationand
treatmentofcognitivedevelopmentissues?Includetheindividual'squalifications.
Limitresponseto500words.
ThisindividualshouldbelistedinStandard1-AccesstoOtherProfessionals.
This question will only be shown if you indicate No in the previous question.
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36. Describehowpatientswithcognitivedevelopmentissuesaremonitoredovertimesothat
appropriateeducationalservicesareinplacefrominfancythroughadolescence.Ifmonitoring
isdonebyanoutsideservice(e.g.schoolsystem),explainhowtheteamensuresthatthe
patients’needsaremet.
Includetimemarkersintheresponse.Ifmonitoringisdonebyanoutsideservice,theinformationshouldbecomepartofthepatient'srecord.Iftheschoolsystemprovidesthisservice,explainhowtheteamensuresthattheevaluationsareperformedand/ortreatmentisdelivered.
Theteamconductsformalassessmentofcognitivefunctioningofpatientswhendeemednecessary.
37.Describetheteam’sprocessforconductingaformalassessmentofcognitivefunctionona
patientwhoisage4orolderandwhohasacraniofacialconditionrequiringtranscranial
surgery.Indicatethetypesofcognitivepsychometrictestingmostcommonlyusedfor
evaluations.
Examplesofcognitivepsychometrictestinginclude,butarenotlimitedto:
KaufmanAssessmentBatteryforChildren(KABC):LeiterInternationalPerformanceScale,Stanford-BinetIntelligenceScales(SB),WechslerAdultIntelligenceScale(WAIS),WechslerIntelligenceScaleforChildren(WISC),WechslerPreschoolandPrimaryScaleofIntelligence(WPPSI),Woodcock-JohnsonTestsofCognitiveAbilities(WJCog),
*Version/editionnumbersforeachtestareomittedfromthelisttoaccountfornewlypublishedversions;however,testingdocumentationshouldreflectacurrentversionoreditionofthetestatthetimeitwasadministered.
Alongwiththedescribedprocessforconductingtheformalassessment,theteammustlistexamplesofthetypesofcognitivepsychometrictestingthatwouldbemostcommonlyusedfortheteam'spatientsandtheproviderwhoisresponsibleforinterpretingandreportingresultsfromthesetests.
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Standard6:OutcomesAssessmentTheteamusesaprocesstoevaluateitsownperformancewithregardtopatientassessment,treatment,orsatisfactionandtomakeimprovementsasaresultofthoseevaluations
38. Itisrequiredthattheteamsetupaprocesstoself-monitoritseffectivenessandensure
continualimprovementofoutcomes.Teammeetingsalonedonotmeetthestandard.Doesthe
team(NOTindividualpractitioners)haveaformalprocesstoroutinelyevaluateits
effectiveness/outcomes?
__ Yes
__ No
39. Pleasedescribetheprocess.Ifthereisnoteamprocess,describetheplansfor
implementingoneandincludeatimelineforimplementationwithin12months.
Theprocessdescribedshouldbespecifictotheteamasawholeandnottheinstitutionorindividualteammembers.Examplesincluderegular,systematicassessmentofpatientsatisfactionscores,teamprocessimprovementprojectsandmeetings,regularandsystematicreviewofpatientreportedoutcomes.
40. Describeanexampleofhowtheteamhascollectedanduseddatatochangeteam
processes(e.g.,modifysurgicaltreatment,changereferralcriteria).Thisexamplemaybe
resultoftheprocessoutlineinQuestion39orrelatedtoadifferentprocessusedbytheteam.
Thisexamplecanincludeapublishedstudysuchasamanuscriptorsubmittedabstract.
Theresponseshoulddescribehowthepotentialimprovementisidentified,howtheinterventionisplanned,andhowtheresultisassessed.Whoparticipates?Howistheentireteamkeptinformed?
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Optionally,attachdocumentation(e.g.publishedmanuscript,progressreport,presentation)
supportingtheexampledescribedabove.
Limittheattachmenttofivepages.
41. Describetheteam'squalitymanagementsystemforpatient/familysatisfaction,including
anexampleofhowthisinformationhasbeenusedtoinformchanges(e.g.,improving
patient/familyexperiencesinclinic,communicationwithpatients/familiesbetweenvisits,etc.).
Forexample,patient/familiessurveysconductedbytheteamorreportofaPIproject/narrativedescriptionofaproject.
DigitalSignaturefromTeamLeader/Director
Iftheprimaryuseroftheapplicationisnottheteamleader,theteamleaderwillneedtobeaddedasacollaboratortosignthisform.
Toaddacollaborator,go"Backtoapplication,"click"Addcollaborator"andentertheteamleader'semail.ThisindividualwillreceiveanemailfromSurveyMonkeyApplyinvitingthemtocollaborateontheapplication.
DigitalSignaturefromTeamLeader/DirectorACPATeamApprovalApplicationAgreement
IaffirmthatIhavereadthisapplicationinitsentiretyandconfirmtheaccuracyofalloftheinformationcontainedwithinthisapplication.Iaffirmthatpatientidentifyinginformationhasbeenomittedfromallattachments,thatourTeamabidesbyalloftheinformationprovidedherein,andthatallpatientsreceivingcarefromthisTeamaremanagedeitherbyanappropriateTeammember,soidentifiedinthisapplication,orwithfullknowledgeofthepersonevaluatingortreatingpatientsifreferredtoaprofessionalpersonnotspecificallyidentifiedbynameandprofessionwithinthisapplication.
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SignatureofTeamLeader
Usethecursortodrawyoursignature.
PrintedName
Team Leader Name
SignatureofAuthorizedInstitutionalOfficerInorderfortheAIOtodigitallysigntheform,theywillneedtobeaddedasacollaborator.Toaddacollaborator,go"Backtoapplication,"click"Addcollaborator"andentertheteamleader'semail.ThisindividualwillreceiveanemailfromSurveyMonkeyApplyinvitingthemtocollaborateontheapplication.
Alternatively,youmaychoosetouploadtheAIOsignaturebyclickingUploadForm.Ifyouchoosethisoption,theAIOmustsignthelinkedformwithintheuploadoption.Uploadsthatdonotincludeaformandsignaturewillbeconsideredincomplete.
SignaturefromAIO
*Theadministrativeorganizationmaybeahospital,university,corporation,orself-sponsoredprivatepracticegroup.
**Thepurposeofthisrequirementistodocumentthatsomeonewithfiduciaryresponsibilityfortheinstitution/practiceacknowledgesandsupportstheoperationoftheteamatitsfacility.Thiswouldtypicallybethechiefexecutiveofficer,thechiefmedicalofficer,thedeanofthemedicalschoolorcollege,ortheownerofthepracticeinwhichtheteamoperates.Forthispurpose,adepartmentchairisnottheappropriateperson.
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SignatureofAuthorizedInstitutionalOfficer
Theadministrativeorganization*namedbelowseeksACPATeamApprovalofitsCleftPalate,CraniofacialorCross-SpecialtyTeamandherebyappliesforanevaluationofthisteam.
Thesponsoringorganizationagreestocooperatefullyintheevaluationprocedures,includingfurnishingsuchwritteninformationtotheAmericanCleftPalate-CraniofacialAssociation(ACPA)asshallberequiredforevaluationoftheteam.
ThesponsoringorganizationfurtheragreestosubmitACPA’sTeamSelf-AuditingReportannuallyandagreestopaytheannualfeeforsubmission.ThisreportisrequiredeachyeartoremainanACPAApprovedTeam.
Thisapplicationmaybewithdrawnbytheteamwithoutprejudiceatanytimeandforanyreasonbeforeafinaldecision.
Theadministrativepoliciesofthesponsoringorganizationandtheteammustcomplywithfederal,state,provincial,andlocallaws,regulations,orexecutiveorderswithrespecttoequitabletreatmentofpatientswithoutregardtogender,sexualorientation,age,race,religiouspreference,nationalorigin,ordisablingcondition.
Bycompletingthisform,IconfirmthatIqualifyastheAuthorizedInstitutionalOfficer(AIO)**ofthesponsoringorganizationandthereforeholdfiduciaryresponsibilityfortheinstitution/practice.
PleasenoteyourpreferenceforcompletingtheSignatureofAuthorizedInstitutionalOfficer
Usethecursortodrawyoursignature.
_x_ Electronic Signature
__ Upload
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AdministrativeorSponsoringOrganization*
Institution/OrganizationName ACPA
Address 1504EFranklinStSTe102
City ChapelHill
State/Province NC
PostalCode 27514
Country UnitedStates
AuthorizedInstitutionalOfficer(AIO)**
Name JohnJacobs
JobTitle CEO
Phone 919.933.9044
Email [email protected]
AIOSignature**