Closing the Loop Form

Opportunity Name

Health Care Partner (Name/Dept/Org)

Health Care Partner E-mail

Engagement Leader who supported you for this opportunity*

Patient Partner(s)

Patient Partner Term Start Date

Patient Partner Term End Date

Today's Date

Meeting Frequency

Meeting Format

Aim

What was the aim or goal of your initiative?

Patient Involvement Summary

What was the purpose of engaging patient partners in this work? What was the patient partners’ role?

Outcomes

Share how/if the aim of the project has been met. Describe and share the final product, decision or outcome of the work that patient partners have contributed to. Participating in a project and not knowing the end result is like reading a book with the final chapter torn out!

Briefly describe outcomes of the initiative. If the work is ongoing, please provide a summary of progress and decisions made to date.

Do you have any supporting documents that can be shared? Eg. final reports, newly created patient education materials, storyboards, evaluations, etc.

File

Max. file size: 16 MB.

Beyond this form, are there other ways this information has or can be shared with patient partners? Eg. tour of new facility, invitation to future events, etc.

Patient Impact

Share how the contributions and participation of patient partners influenced outcomes. This impact assessment is important for everyone. Patient partners want to know how they made a difference. You and your team can learn from this experience to inform future patient engagement work. The PVN program keeps this information for program evaluation purposes. Please note: this is not intended to be a “performance review” of the patient partner.

Briefly describe the ways in which the patient partner(s) influenced outcomes.

Please provide at least one concrete example.

Close Out & Thank You

Ensure that the patient partner(s) know that the project, or their involvement with it, has ended. Share your appreciation for the patient partners’ volunteerism!

Confirm that the following final actions have been completed:

Patient partner(s) are aware that their participation in this initiative is now complete and have been thanked for their contributions.
Patient partner expenses for participation (eg. mileage/parking) have been reimbursed as agreed at the start of the engagement.

Comments

If additional outcome of impact information is not yet available, when can PVN staff follow up with you?

Permission to Share

I am aware that PVN will share this form and uploaded attachments with the Patient Partners.
I provide consent for the BCPSQC (PVN) to share the information I provided in its communication vehicles (examples include blogs, newsletters and on their website).

Do you have suggestions on how to improve this form or the PVN Closing the Loop process?

Closing the Loop Form

Aim

Patient Involvement Summary

Outcomes

Patient Impact

Close Out & Thank You

From Our Community

Laura Klein