Applicants:Please complete, save and return this form to your Local Health District Program Sponsor by COB 7 June 2019.

(please DO NOT click the Submit Form button at the top of screen.)

Applicant’s details

Surname Staff Link ID

LHD

Yes No

Title First Name

Professional position

Organisation

Have you undertaken any leadership training previously?

If yes, provide details:

When did you complete this training?

Last 12 months Last 3 years Last 5 yrs Over 5 yrs

Yes, Torres Strait Islander

Are you of Aboriginal or Torres Strait Islander origin?

Your contact details for program communications:

Mobile

(this is the email address we will use for all communication)

Your individual local health district (or other) SPONSOR during the program:

Professional position

LHD

State Postcode

Mobile

Name

Organisation

Address

Suburb

Phone (bus hours)

Email (work)

Approval by Sponsor: YES, submission approved Approval Date:

For further information, contact your Program Sponsor or the CEC: Wendy Jamieson, Senior Manager,Quality Improvement Academy0434 078 026

Mel Donat Project Officer, QI Academy 02 9269 5607 CEC-CLP@health.nsw.gov.au

http://www.cec.health.nsw.gov.au/quality-improvement/improvement-academy/qi-academy-curriculum/statewide-scheduled-training/exec-clp

EXECUT IVE CLINICAL LEADERSHIP PROGRAM APPLICATION FORM – COHORT 23: AUGUST 2019 INTAKE

Yes, both Aboriginal and Torres Strait IslanderNo Yes, Aboriginal

Phone (bus hours)

Email (work)

1. Please give your reasons for your application to the Executive Clinical Leadership Program (maximum 50 words).

2. Please describe the clinical team/ stream /network that you work within (maximum 50 words).

3. Do you plan to undertake any additional formal/informal study during the next year? If so, how would you balance theworkload required from both programs of learning? (maximum 50 words)

4. Please describe your leadership role (maximum of 100 words)

5. Please provide examples of your commitment to system improvement and safety in health care (maximum 100 words)

What is your current your leadership position? No formal leadership role, Department leadership role, Hospital-wide leadership role LHD/AHS-wide leadership role

Other (Please specify)

In applying to the Clinical Leadership Program;

YES, I acknowledge that I have discussed my active participation in the Clinical Leadership Program with my line manager. I am able to be released from normal duties to participate in the six learning modules (12 days) and to undertake an improvement project. I do not foresee any reasonable circumstances that would preclude me from completing the program in the required timeframe.

Applicant Name: Date:

Common errors in selecting projects include:

• Selecting a problem beyond your authority or outside of your influence

• No one else is interested in the problem

• Selecting a solution to implement rather than a problem to investigate

• Selecting a process in transition

6. Outline your proposed Improvement Science Project and why your team/unit needs to review the practice?(maximum 250 words). In your response, please state:• What is the problem worth solving?

• Why is the problem important to the organisation and its customers?

• Who else thinks it is a problem worth solving?

• Is there supporting evidence qualitative or quantitative that there is a problem?• Is there evidence available relating to best practice?