Read HOSPITAL%20SURVEY%20QUESTIONNAIRE.pdf text version

Dear Dr. / Sir / Madam, Greetings from Spurthi Meditech! We a r e delighted in informing you that Spurthi Meditech (TPA) Solutions Pvt Ltd have been licensed by IRDA as an approved Third Party Administrator. It will be our pleasure in assisting you to empanel your esteemed institution a s o u r preferred Service Providers. Spurthi Meditech TPA Solutions Pvt Ltd has been shaped by a group of experienced professionals from the insurance and healthcare industries to bring in rich domain knowledge and deep understanding of business. The Vision of Spurthi Meditech is to emerge as a preferred player bridging the service providers and customers with supreme operational efficacy . Please find enclosed the Hospital Survey Questionnaire and kindly return the same duly filled along with your latest detailed tariff at the earliest. We will truly appreciate if you can provide the soft copy of your tariff and mail us at [email protected] On receipt of the documents, our medical team will review the information and will communicate the empanelment status to you. For any further information in this regard, please feel free to contact the undersigned. Spurthi Meditech looks forward for a long and mutually beneficial relationship. Thanking you, Yours Truly,

Dr. B. Ravi Kishore Chief Medical Officer Ph: 080 40111162 Mob: +91 9686194814

Regd. Office: No. 82 | `Maruthi Ramakrishna Arcade' | 2 Floor | Dr. Rajkumar Road | Rajajinagar 2 Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: [email protected] / Web: www.spurthimeditech.com

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HOSPITAL SURVEY QUESTIONNAIRE

Name of the Hospital

:

Address

:

District Sub-District Name of the Gram/Panchyat Village State Contact person's Name Mobile Number E-Mail ID

: : : : : : : :

Regd. Office: No. 82 | `Maruthi Ramakrishna Arcade' | 2 Floor | Dr. Rajkumar Road | Rajajinagar 2 Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: [email protected] / Web: www.spurthimeditech.com

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A. Basic Information about the respondent Details of the person filling in the Questionnaire A.1a Name A.1b Age A.1c Are you in charge of this Facility A.1d Designation A.1e Qualification B. Characteristics of the Hospital Type of Facility B.1 Type Status Code Public facility Private for Profit Private not for Profit Remarks Status Code Remarks

1- Yes, 2- No.

C. Empanelment / Accreditation Item C.1a Has the hospital been empanelled by a Health Insurance / Other Schemes C.1b If yes, by how many ( Give Details ) C.1c Has the hospital been accredited/ certified by any agency ? C.1d If yes by whom? ( Furnish Details ) D. Information on Staff.

How many workers work at this facility in total ( On roll Employees)?...................... (Here workers refer to Doctors, Nurses, Paramedical staff, Laboratory technicians and Pharmacist and other non-medical persons)

Status Code 1- Yes 2- No Public Agency Private Agency 1. Yes 2. No

Remarks

List Workers by name Category of Staff D.1 Doctors and Nurses D.1a Doctors with Post Graduate Qualification (MD,MS,MCh,DNB) D.1B MBBS Doctors

Total Number

On Hospital Rolls

Contractual/ other arrangements

Not Applicable / Service Not available

Regd. Office: No. 82 | `Maruthi Ramakrishna Arcade' | 2 Floor | Dr. Rajkumar Road | Rajajinagar 2 Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: [email protected] / Web: www.spurthimeditech.com

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D.1c AYUSH Doctors D.1d Total No of Nurses (Senior and Junior) D.2 Paramedical Staff D2a OT Staff D.2b Pathology Lab D.2c Radiology Lab D.2d Others D.2e Pharmacists D.2f Other Medical Personnel D.3 Other Non-Medical Person D.3a Peons / Ward Boys D.3b Sweepers D.3c Security Personnel D.3d Any Other Categories

E. Physical Infrastructure- Current Size of the Hospital / WARDS and PRIVATE ROOMS. ITEM Size(Area) of the Hospital (Plot Size in Sq Meters) Number of indoor beds Remarks

E.1a

E.1b

Availabl e

Functionin g

Temporar y / in Corridors

E.1b1

E.1c

E.1.c1 E.1.1c2

Number of ICU beds (ICU/ICCU/NICU/PICU/ HDU) Total Number of Patient Toilets Male Female

Regd. Office: No. 82 | `Maruthi Ramakrishna Arcade' | 2 Floor | Dr. Rajkumar Road | Rajajinagar 2 Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: [email protected] / Web: www.spurthimeditech.com

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E.2

Total Number of Toilets for Staff How Many Wards do you have? ( Number to be given) List the wards by Name general, Specialist by gender No of Major OTs No. of Minor OTs No. of Labor Rooms No. of Emergency Beds How Many private rooms do you have?

E.3a

E.3b

E.3c E.3d E.3e E.3f E.4

F. Availability of Services. Services Specialist Services General Medicine General Surgery Obstertic & Gynaecology Paediatrics Emergency Services (24 Hours) Neonatology Anesthesia Status Code 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Remarks

F.1a F.1b F.1c F.1d F.1e F.1f F.1g

Regd. Office: No. 82 | `Maruthi Ramakrishna Arcade' | 2 Floor | Dr. Rajkumar Road | Rajajinagar 2 Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: [email protected] / Web: www.spurthimeditech.com

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F.1h F.1i F.1j F.1k F.1l

Orthopedics ENT Radiologist and Ultrasonologist Ophthalmology Dermatology and Venereal Diseases (Skin & VD )RTI / STI Dental Care AYUSH

1. 2. 1. 2. 1. 2. 1. 2. 1.

Yes No Yes No Yes No Yes No Yes

2. No 1. 2. 1. 2. Yes No YES NO

f.1m f.1n

f.1o Others, Specify.

G. Support Services. Support Services Available G.1 Finance ( Financial Accounting ) Availability? 1. Yes 2. No G.2 Ambulance Services-Number Dietary Services 1. Yes 2. No 1. Yes 2. No Outsourced? 1. Yes 2. No Outsourced: In-house: Outsourced In-house If Outsourced Written Contract-1 No Written Contract-2 If Outsourced Written Contract: No Written Contract: If Outsourced Written Contract-1 No Written Contract-2

G.3

Regd. Office: No. 82 | `Maruthi Ramakrishna Arcade' | 2 Floor | Dr. Rajkumar Road | Rajajinagar 2 Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: [email protected] / Web: www.spurthimeditech.com

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G.4

Laundry Services

1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No

Outsourced In-house Outsourced In-house Outsourced In-house Outsourced In-house

G.5

Security Services

G.6

House Keeping and Sanitation Counseling Services for Domestic violence, Gender Violence, Adolescents, Etc

If Outsourced Written Contract-1 No Written Contract-2 If Outsourced Written Contract-1 No Written Contract-2 If Outsourced Written Contract-1 No Written Contract-2 If Outsourced Written Contract-1

G.7

No Written Contract-2

H. Hospital Processes No H.1a Process Were the financial reports for the last 2 years audited by professional Chartered Accountants? Is there a dedicated doctor for handling emergency situations 24x7 If yes, what are the qualifications of that doctor? B.Sc. Nursing /GNM is in charge of each ward? Are regular doctors' rounds for all wards performed? Status 1. Yes 2. 1. 2. 1. 2. 1. 2. 1. 2. No Yes No Yes No Yes No Yes No Remarks

H.1b H.1c H.1d H.1e

Regd. Office: No. 82 | `Maruthi Ramakrishna Arcade' | 2 Floor | Dr. Rajkumar Road | Rajajinagar 2 Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: [email protected] / Web: www.spurthimeditech.com

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H.1f

H.1g

H.1h

Is there a mechanism for planned maintenance of equipment(Including AMCs) Are the radiologist and ultrasound machine registered under the PNDT Act? Does a female attendant accompany all female patients during investigations and consultation Are all areas of hospital swept at least twice a day? Is the OT is carbolised after each surgery? Is the Labor room carbolised after each surgery ? Is the hospital registered under the BioMedical Waste Management Rules 1998? Are mortuary services available/made available whenever required? Is the blood bank providing blood registered with Drugs and Cosmetics Act ? Is there a mechanism to obtain patient feedback regularly? If yes what is the type of mechanism available Form

1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. Yes No Yes No Yes No Yes No Yes No Yes No

H.1i H.1j H.1.k H.1.l

H.1.m H.1.n

H.1.o H.1.p

1. Yes 2. No 1. 2. Register 3. Verbal 4. Suggestion Box

H.1.q

Are medical records maintained for all inpatients for a period of at least 5 years

1. Yes

2. No

Regd. Office: No. 82 | `Maruthi Ramakrishna Arcade' | 2 Floor | Dr. Rajkumar Road | Rajajinagar 2 Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: [email protected] / Web: www.spurthimeditech.com

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H.1r

Is there any provision for centralized Medical Gas Supply? Is there any Generator back up?

1. Yes 2. No 1. Yes 2. No

H.1s

H.1t

Is there any UPS back up?

1. Yes 2. No

H.1u

Is there any Water purification facility available? Is there any Insurance Help Desk facility available?

1. Yes 2. No 1. Yes 2. No

H.1v

I. Outpatient / In Patients Statistics

Name of Speciality 1. 2. 3. 4. Others

Average Number of Outpatient cases during MONTH

Total Number of Inpatient admissions during calendar year

"THIS INFORMATION COLLECTED WOULD BE KEPT CONFIDENTIAL AND THIS WILL BE USED ONLY FOR EMPANELLING YOUR HOSPITAL WITH SPURTHI MEDITECH (TPA) SOLUTIONS PRIVATE LIMITED AND NOT FOR ANY ANOTHER PURPOSES"

Empanelling into Spurthi Meditech (TPA) Solutions Private Limited does not necessarily assure you 100% of business. It is an opportunity for your business to grow but our intention is only to provide wider options for the customer to choose from and gives you a benefit of servicing all our customers health that is covered by our services.

WE THANK YOU AND YOUR TEAM FOR GIVING YOUR VALUABLE TIME AND DATA

Our team will scrutinize the data produced and shall revert back to you for further or next level of SLA and Business Continuity Plan with Provisional/Suggested Package Rates for medical and surgical interventions/procedures with Codes.

Regd. Office: No. 82 | `Maruthi Ramakrishna Arcade' | 2 Floor | Dr. Rajkumar Road | Rajajinagar 2 Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: [email protected] / Web: www.spurthimeditech.com

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