PSLF Form

Home

AHA-NPSF Comprehensive Patient Safety Leadership Fellowship

Thank you for applying for the AHA-NPSF Comprehensive Patient Safety Leadership Fellowship. If you have questions, please contact fellowships@aha.org, or (312) 422-2933.

Before you complete this online application, please carefully review the entire brochure. You will need the following documents in order to successfully submit an application. Applications cannot be saved for future use. PLEASE BE SURE YOU HAVE ALL COMPONENTS COMPLETE AND AVAILABLE. You will need to attach the following items:
- Resume or curriculum vitae
- Signed letter of support from your organization
- Two (2) letters of reference
- Photo –please attach a head shot photo of yourself facing forward, jpeg format, at least 300 dpi (ideal size (approximately) 200 x 315)
Total file size must be less than 7 MB. If files are larger, please email them to fellowships@aha.org.
Demographic/Contact Information

*Full Name:

Nickname:

Title:

Credentials:

Organization:

Address:

City:

State:

Zip:

Country:

*Phone (International applicants please be sure to include the country code):

Fax (International applicants please be sure to include the country code):

*Email:

Assistant Name:

Assistant Phone:

Assistant Email:

Type of Organization:

Project Information

NOTE: It is understood that all proposals are works in progress; they should be realistic and have actionable objectives that can be completed by the end of the fellowship year. Projects may undergo modification to fully meet program objectives.

*Are you part of a team submission?

*Has another member of your team filled out the problem/aim/scope section of the application? (Details of the project only need to be filled out by ONE member of each team. However, each team member must fill out the demographic/contact information and submit required documents.)

Proposed Title:

Summary - Provide a brief summary of the project:

*Project Title/Name:

Problem - What is the safety concern you plan to address through your Action Learning Project? What is the nature of the problem and why is it important to your organization to resolve? (250 word limit):

Aim Statement - What measurable safety improvement do you want to accomplish? Must include measures, goal and timeline. (Example: Decrease the all-cause readmission rate for heart failure patients by 20 percent in 12 months):

Key Measures - How will you know if you are successful? You may list up to three specific measurement areas that will be tracked throughout the course of the project.

Measure #1 - include description, current process/practice and improvement goal

Measure #2 - include description, current process/practice and improvement goal

Measure #3 - include description, current process/practice and improvement goal

Scope - What specific action steps/activities will be employed to reach your goal(s)? How does the project align with existing initiatives within the organization?

Resources - Resources needed to support your goal(s), include FTEs, technology and training.

Application Material

Please attach the following information:
- Resume or curriculum vitae
- Signed letter of support from your organization
- Two (2) letters of reference
- Photo –please attach a head shot photo of yourself facing forward, jpeg format, at least 300 dpi (ideal size (approximately) 200 x 315)
Total file size must be less than 7 MB. If files are larger, please email them to fellowships@aha.org.

Select A File To Upload:

Select A File To Upload:

Select A File To Upload:

Select A File To Upload:

Select A File To Upload:

Recaptcha:

This system will not allow you to save or make changes once this form is submitted. You will receive email notification shortly that your application was received. Thank you for your interest in the AHA-NPSF Comprehensive Patient Safety Leadership Fellowship.

Hospitals in pursuit of excellence

AHA-NPSF Comprehensive Patient Safety Leadership Fellowship

Demographic/Contact Information

Project Information

Application Material