Award Application

Organization Name (all client identifying information will be blinded to the judges)

Name of person completing application

Title

Email / phone number

MCG Account Executive

Please select the one that best describes your organization:

National health plan or other payor (e.g. TPA)Regional or local health plan or other payorHospital system with three or more facilitiesLarge hospital (more than 300 beds total)Medium or small hospital (fewer than 300 beds total)Accountable Care Organization Critical Access HospitalGovernment-funded health serviceOther (specify):

Please select the MCG solutions pertinent to this application:

Cite AutoAuth Module Ambulatory CareCite Care Integrated Behavioral Health CareCite CareWebQI Chronic CareIndicia General Recovery CareGuideline Analytics Home Care

Inpatient & Surgical Care Multiple Condition ManagementPatient InformationRecovery Facility Care

Please provide a brief description of your effective care initiative in 500 words (3,500 characters) or less. Use additional pages if necessary. Please omit your organization name and other elements that might identify you, such as “presented at the XYZ conference in Detroit.”

Question 1 Weight and Word Count LimitExplain how your initiative helps drive effective care.

(Weight: 20%)250 words (1,700 characters) or less

Question 2 Weight and Word Count LimitDescribe how this initiative influenced other departments, divisions or regions within your organization.

(Weight: 10%)250 words (1,700 characters) or less

Question 3 Weight and Word Count LimitDescribe the impact this initiative has had on your organization – comparing your status before you began with where you are now. Please use quantitative and qualitative descriptions, and quantify with metrics where possible.

(Weight: 20%)250 words (1,700 characters) or less

Question 4 Weight and Word Count LimitDescribe how your senior leadership supported this initiative.

(Weight: 10%)250 words (1,700 characters) or less

Question 5 Weight and Word Count LimitIn what ways does this initiative transform healthcare?

(Weight: 10%)250 words (1,700 characters) or less

Question 6 Weight and Word Count LimitDescribe the impact this initiative has had within your organization on any of the following areas. Please quantify with metrics where possible. Quality improvement or patient safety Patient or member satisfaction Staff efficiency, productivity, or

satisfaction Provider or payor satisfaction or

communication Other external agency satisfaction Cost (utilization, fixed cost, patient

throughput)

(Weight: 30%)500 words (3,500 characters) or less

Application GuidelinesPlease omit all identifying information from your application EXCEPT on the application’s first page.

Each client organization may submit no more than two initiatives for consideration. Each initiative must be submitted as a separate application.

We encourage you to include any charts or graphs that support your written responses in an appendix. These materials will not be subject to the word count limits, but we ask that you limit the appendix to ten pages total.

How to Submit Your ApplicationYou may submit your application digitally via email with a digital signature.

Email applications to:scarlet.leung@mcg.comSubject Line: 2016 Doyle Award Submission

Deadline to SubmitThe application deadline is Friday, September 16, 2016 for email receipt.

AgreementBy submitting this application for the Doyle Award, the Organization agrees to attend MCG’s Client Forum 2017 and to present its initiative, if selected as a Doyle Award winner. In addition, Organization agrees to work with MCG to develop and distribute a mutually acceptable press release and case study, and to participate in a video profile created by MCG. The Organization hereby agrees that MCG may record any presentation by Organization by audio or video recording and the Organization grants MCG the royalty-free worldwide right to use, reproduce, distribute, display, and perform the recording and video profile for its business purposes.

Organization Name

Name

Title

Date