Safety Star for Healthcare Facilities Nomination Form

To nominate a healthcare facility for the Safety Star Award, complete the form below.

Nominations must be received by October 13, 2023.

Steps to Submit a Complete Award Nomination:

  • Complete the nomination form and save a copy. A summary of your responses will be emailed to you after submission.
  • Ensure that each component of the nomination has been addressed.
  • Submit the nomination by Oct. 13, 2023.

A. General Information

1. Organization (must be a member of the LHA Malpractice and General Liability Trust)


2. CEO/Administrator of Applying Organization

3. Project Coordinator

Nomination Submitted By

B. Project Information

State the violence in healthcare opportunity that was identified in your organization including the population that was identified as a concern related to the problem.

Discuss how the determination was made that a problem existed. Please include data and other resources to support the decision to begin the project.

Define the specific goal(s) which were set forth for this project, including the measurable objectives which were developed to measure progress toward the goal. When writing measurable objectives please remember that they should be time specific and indicate exact expectations. For example: Falls will be decreased by 25% within 6 months.

Discuss the project plan. This section should include a discussion of the plan to achieve the goals, including budgetary plans, human and material resources anticipated, and overall expected outcome of the project.

Discuss how the project was rolled out and who was involved (specifically which departments or other stakeholders). Discuss the project timeline of events. Discuss applicability of the projects to other organizations. List barriers that were encountered and how they were overcome.

Summarize the results achieved, discuss the data and the metrics used to determine success and the outcomes achieved. Specifically, address in detail the improvement in outcomes from the beginning to conclusion of monitoring.

Summarize how the project has impacted and reduced the potential for violence in your organization. Were any other positive impacts identified as a result of the project that were not foreseen or not measurable?

Supporting Information

Please attach any supporting information that you have to support your improvement. The maximum allowed upload size is 64MB. Files must be uploaded as PDF or image format.