Key Stakeholder List

and Primary VTE Prevention Project Responsibilities
An important first step in any health care system quality improvement project is to clearly delineate roles and responsibilities of internal stakeholders, particularly those of senior leadership. This form (also provided as a nativeformat MS Word file) provides a place where senior leadership members of a hospital’s VTE Prevention Team can be identified and their primary project responsibilities (based on suggestions found throughout this Guide) can be documented. This, along with the Aim Statement, will help team members to develop a shared vision and understanding of how the hospital’s VTE Prevention Project will be implemented.

Chief Executive Officer
Name: Primary Project Responsibilities: Phone: E-mail:

Designated Board of Directors Project Representative
Name: Primary Project Responsibilities: Phone: E-mail:

Designated C-Suite Champion
Name: Primary Project Responsibilities: Phone: E-mail:

Chief Medical Officer
Name: Primary Project Responsibilities: Phone: E-mail:

Designated Project Physician Champion
Name: Primary Project Responsibilities: Phone: E-mail:

Chief Nursing Officer
Name: Primary Project Responsibilities: Phone: E-mail:

Chief Quality Officer
Name: Primary Project Responsibilities: Phone: E-mail:

Chief Pharmacy Officer
Name: Primary Project Responsibilities: Phone: E-mail:

Chief Information Officer
Name: Primary Project Responsibilities: Phone: E-mail:

Designated Project Day-to-Day Leader/QI Team Facilitator
Name: Primary Project Responsibilities: Phone: E-mail:

Other:
Name: Primary Project Responsibilities: Phone: E-mail:

Health Services Advisory Group, Inc.

Translating VTE Guidelines Into Practice
Project supported by sanofi-aventis, U.S.

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