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Southwest Hospital

Patient and Family Advisory Council Application

Understanding the care experience from the perspectives of our patients and their families is a key factor in delivering healthcare quality, safety and service. In our ongoing efforts to provide exceptional patient care, we are enlisting the assistance of former patients and their families to share their perspectives, insights and experiences.

We are currently in the process of selecting patients and family members to help us create a sustainable Patient and Family Advisory Council (PFAC). The new council will provide a forum that encourages patients and families to actively participate in improving the patient experience at Memorial Hermann Southwest by serving as an advisory resource for staff and leadership. Feedback from the council will be used to inform and improve hospital operations, patient safety, employee engagement/satisfaction, and the patient experience.

The estimated monthly time commitment for the PFAC would be 2 hours per meeting every quarter. If you would be interested in serving on the Memorial Hermann Southwest PFAC, please complete this short application. Selected applicants will be contacted to schedule an interview. If you have any questions, please call Gerald Hatter at (713) 456-5655.

  

 First name:
 

Last name:
 

Address:
 

City:
 

State:
TEXAS

Zip:
 

Daytime phone:
 

Email address:
 

Age:

 

I am:

 

Are there certain topics or areas of the hospital in which you have a special interest?

In what area(s) are you interested in representing? Please check all that apply.

         


Why are you interested in Joining the Patient and Family Advisory Council?


If you have participated in any organizations or committees, please share some examples: (These may be from work, community, church)


What positive improvements to patient care would you like to see as a result of your participation in the Patient and Family Advisory 
Council?


Do you have any dietary needs we should be aware of? (i.e., vegetarian)


Electronic Signature:
 


REMINDER: WE WILL DO BACKGROUND CHECKS ON ALL COMMITTEE MEMBERS, AND A HEALTH SCREENING (FLU AND TB) IS REQUIRED BEFORE YOU JOIN AND ANNUALLY GOING FORWARD. MEMBERS MUST SIGN A CONFIDENTIALITY AGREEMENT. WE WILL KEEP APPLICANTS IN MIND FOR POTENTIAL OPPORTUNITIES FOR FUTURE PROJECTS.