empanelment application & criteria

8/14/2019 Empanelment Application & Criteria

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Government of Karnataka

SUVARNA AROGYA SURAKSHA TRUST

APPLICATION & CRITERIAFOR

ACCREDITATION OF HOSPITAL

PHI building, Sheshadri Road, K.R.Circle, Bangalore


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1. Name of the Hospital:

2. Address:

3. Ownership:Is the hospital a public / government establishment or an independent / private sector provider?

4. Year in which established & Built area of the hospital:_____________________________________________________________________________________

5. Contact Person(s):

(Please indicate [] with whom correspondence to be made)

Chief Executive Officer: (or equivalent)

Mr./Ms./Dr._______________________________________________________________________

Designation: ______________________________________________________________________

Tel: ______________________________ Mobile:________________________________________

Fax: ____________________________________________________________________________

E-mail:__________________________________________________________________________

Hospital Coordinator:Dr.____________________________________________________________________________

_(Allopathic doctor)

Designation: ______________________________________________________________________

Tel: ______________________________ Mobile:________________________________________

Fax: ____________________________________________________________________________

E-mail:__________________________________________________________________________

6. Hospital registration no & date:_____________________________________________________________________________________Please enclose the copy of hospital registration certificate. 1


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7. PAN No. of the Hospital:_____________________________________________________________________________________

8. Bank Details:

Bank Name: __________________________________________________________________________

Name of the Bank ccount:________________________________________________________________

Account Number:________________________________________________________________________

Branch Name:___________________________________________________________________________

IFSC Code:_____________________________________________________________________________

9. Number of Inpatient Beds:

(Please mention no. of existing beds in the appropriate box) [Please enclose the photograph of general ward]

a. 100

No. of beds earmarked for Male patients:

No. of beds earmarked for Female patients:

10. Number of ICU Beds:(Please mention no. of existing beds in the box and if not available mention as NA)

a. Intensive Care Unit Adult:

Description of the equipment available in ICU ward (adult):

__________________________________________________________________________________

[Please enclose photograph (post card size) of equipment in working condition]

b. Intensive Care Unit Pediatric:

Description of the equipment available in Pediatric ICU:

___________________________________________________________________________________

[Please enclose photograph (post card size) of equipment in working condition] 2


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c. Neonatal ICU:

Description of the equipment available in Neonatal ICU:

______________________________________________________________________________________________________________________________________________________


d. Post operative ward:

Description of the equipment available in post operative ward:________________________________________________________________________________

_______________________________________________________________________________


e. Step down ICU Beds:

Description of the equipment available in Step down ICU:________________________________________________________________________________

________________________________________________________________________________ [Please enclose photograph (post card size) of equipment in working condition]

f. Please mention the no. of ventilators available in the hospital:

11. OPD & IPD data:OPD DATA (Past three years)

Period Number of Patients

2006-20072007-20082008-2009

IPD DATA (Past three years)

Period Number of Patients2006-20072007-20082008-2009


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12. Specialties Available / Clinical services provided by the Hospital:

Sl.No.

Clinical Service/specialties ServiceProvided[YES/No]

Totalbeds

available

Bedsavailablein ICU

Bedsavailable in

Post Opfacility

Bedsavailable inStep down

ICU1 Burn Unit

2 Cardiology3 Cardiothoracic Surgery4 Coronary Care Unit5 Day Care Treatment

Endoscopy6 Day Care Treatment

Bronchoscopy7 Dermatology8 Dentistry9 Dialysis10 Emergency Medicine11 Ear Nose Throat12 Endocrinology13 Gastroenterology14 Gastrointestinal (GI) Surgery15 General Medicine16 General Surgery17 Genito Urinary Surgery18 Gynaecology and Obstetrics19 Infectious Diseases20 Laser Treatment

21 Nephrology22 Neurology23 Neurosurgery24 Medical Oncology25 Radiation Oncology26 Surgical oncology27 Ophthalmology28 Oral surgery29 Orthopaedic Surgery30 Plastic surgery31 Paediatric Surgery

32 Palliative Care33 Prosthesis34 Polytrauma35 Pulmonology36 Rehabilitation37 Respiratory Medicine38 Rheumatology39 Transplantation Services40 Urology

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13. Specialty wise infrastructure available:

Sl.No

Specialties Cases handled inlast two years

Overall % ofoccupancy

Anesthetistround the

clock[Yes/No]

OTfacility

SterilityUnit

2007-08 2008-09

1 Burn Unit2 Cardiology3 Cardiothoracic Surgery4 Coronary Care Unit5 Ear Nose Throat6 Endocrinology7 Gastroenterology8 Gastrointestinal(GI) Surgery9 General Medicine10 General Surgery

11 Genito Urinary Surgery12 OBG13 Infectious Diseases14 Laser Treatment15 Nephrology16 Neurology17 Neurosurgery18 Medical Oncology19 Radiation Oncology20 Surgical oncology21 Ophthalmology

22 Oral surgery23 Orthopedic Surgery24 Plastic surgery25 Pediatric Surgery26 Polytrauma27 Pulmonology28 Respiratory Medicine29 Rheumatology30 Transplantation services31 Urology

Note:

1) Please furnish the separate list about name of the anesthetists, reg. no. qualification, no. of years oexperience, university name and mobile no.

2) Further furnish the photograph (post card size duly attested by the authorized signatory with seal andsignature) of the equipment available in OT along with equipment make details.

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14. Specialists Information:Note: Provide information only about cases handled in your hospital.

Sl.No

ClinicalService/specialties

Name ofthe

specialist

Qualification

Reg. no. Years of exp.

Fulltime / on

call

No. ofcases

handled1 Burn Unit2 Cardiology

3 Cardiothoracic Surgery4 Coronary Care Unit5 Day Care Treatment

Endoscopy6 Day Care Treatment

Bronchoscopy7 Dermatology8 Dentistry9 Dialysis10 Emergency Medicine11 Ear Nose Throat12 Endocrinology13 Gastroenterology14 Gastrointestinal (GI)

Surgery15 General Medicine16 General Surgery17 Genito Urinary Surgery18 Gynaecology and

Obstetrics19 Infectious Diseases

20 Laser Treatment21 Nephrology22 Neurology23 Neurosurgery24 Medical Oncology25 Radiation Oncology26 Surgical oncology27 Ophthalmology28 Oral surgery29 Orthopaedic Surgery30 Plastic surgery

31 Paediatric Surgery32 Palliative Care33 Prosthesis34 Polytrauma35 Pulmonology36 Rehabilitation37 Respiratory Medicine38 Rheumatology39 Transplantation services40 Urology

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15. Diagnostic & Other Services being provided by the Hospital:

Sl. No. Diagnostic Service In house [Yes/No] Outsourced [Yes/No]

A. Diagnostic Imaging:1 MRI Scan2 CT Scan3 PET Scan4 Gamma camera5 Ultrasound6 X-Ray7 ECHO8 ECG9 Others

B. Laboratory Services:1 Clinical Biochemistry2 Clinical Pathology3 Haematology4 Clinical Microbiology & Serology5 Histopathology6 Cytopathology7 Genetics8 Molecular Biology9 Blood Bank 10 Blood Transfusion Services

11 others

[Please enclose photographs of basic Pathological, Biochemical, Microbiology & serologyand hematology investigations][Please enclose photographs of USG Scan, ECG, ECHO and X-Ray with make details][For outsourced diagnostic facilities and ambulance service furnish the affidavit as perthe enclosed format]

C. Pharmacy1 Pharmacy available round the

clock

D. Professions allied to Medicine1 Dietetics2 Physiotherapy3 Occupational Therapy4 Speech and Language Therapy5 Ambulance Service

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16. Staff Information: (append the list for all)

Group Number Qualification Experience Remarks if anyManagerialResident

DoctorsConsultantsa) Full timeb) Part timeNursesTechniciansParamedicalOthers

17. Non Clinical and administrative Procedures:

Support service In house (Yes /No) Out sourced (Yes/No)Provision of food / pantryCleaning ServicesGeneral AdministrationLaundryManagement of clinical wasteMortuary ServiceSecurityTechnical department /Equipment ManagementOther Specify

Application filled up date:_____________________

Authorized Signatory

Name:__________, Designation:_______________

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SUVARNA AROGYA SURAKSHA SCHEME

EMPANELMENT APPLICATION-CHECKLIST

Sl.No.

Particulars Enclosedyes/no

Remarks ofSAST

1 Copy of hospital registration certificate2 Photographs of equipment available in ICU-Adult

(duly attested by authorized signatory with seal)3 Photographs of equipment available in ICU-Pediatric

(duly attested by authorized signatory with seal)

4 Photographs of equipment available in Neonatal ICU(duly attested by authorized signatory with seal)

5 Photographs of equipment available in Post Operativeward (duly attested by authorized signatory with seal)

6 Photographs of equipment available in Step downICU (duly attested by authorized signatory with seal)

7 The list about name of the anesthetists, reg. no.qualification, no. of years of experience, universityname and mobile no.

8 Photographs of equipment available in OT inrespective specialties

9 The list of all specialists available in the hospitalcontaining the information such as Name,Qualification, Registration No., Years of experience,Full time/on call and no. of cases handled in therespective hospital.

10 Photographs of all equipment with make detailsavailable under diagnostic facilities.

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SUVARNA AROGYA SURAKSHA TRUST

CRITERIA FOR ACCREDITATION OF NETWORK HOSPITALS

1. The hospital should have at least 50 beds for empanelment with following infrastructure:

A. General Ward:

1 Nurse : 10 patients with 24hrs service in 3 shifts in a day. 1 duty doctor : 10 patients with 24hrs service in 3 shifts in a day. The space between two beds should be at least 5 feet. The provider should have separate male and female wards.

B. ICU Beds:

The hospital should have at least 3 beds 1 Nurse : 1 patient with 24hrs service in 3 shifts 1 duty doctor : 4to 5 patients with 24 hrs service in 3shifts The ICU ward should be equipped with ventilators, defibrillators, monitors, central oxygen line,

suction apparatus and pulse oxymeter.

C. The Step down ICU ward:

The hospital should have at least 2 beds 1 Nurse : 3 patients with 24hrs service in 3shifts. 1 duty doctor : 4to 5 patients with 24 hrs service in 3shifts. The step down ICU ward should be equipped with defibrillators, monitors, central oxygen line,

suction apparatus and pulse oxymeter.

D. The post operative ward:

The hospital should have at least 2 beds 1 Nurse : 1 patient with 24hrs service in 3shifts. 1 duty doctor : 4to 5 patients with 24 hrs service in 3shifts. The post operative ward should be equipped with ventilators, defibrillators, monitors, central

oxygen line, suction apparatus and pulse oxymeter.

Note: Fully qualified nursing staff and allopathic doctors should be available round the clock asaforesaid under the protocol of the hospital. Further ICU is not essential for ophthalmology specialtyhospital.


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2. Infrastructure Conditions: Please tick as per the availability.

The hospital should comply with the following criteria at least under one specialty. Further if the hospitalis Multi-specialty and fulfills the criteria under various specialties, then hospital shall provide its servicesunder all specialties empanelled under the Scheme.

No. SpecialtyPlease Tick

A. SURGICAL SPECIALTIES1 General Surgery

Qualified General Surgeon with post graduate degree in General Surgery Well Equipped theatre facility with trained staff Post-op with Ventilator Support SICU Facility Availability of support specialty of General Medicine, Pediatrics The surgeon should have performed at least 100 cases

1a For Laparoscopic SurgeriesSurgeon having requisite training and having performed at least 100 procedures for laparoscopic surgery (documentary evidence to beproduced)

2 Orthopedic SurgeryQualified Orthopedic Surgeon Well equipped theatre with C-Arm facility Trained paramedics Well equipped Post-op facility with Ventilator Support Round the clock lab support with CT,MRI

3 Gynecology and ObstetricsQualified Gynecologist Expertise trained in laparoscopic procedure with minimum 100performances

Well Equipped theatre Post-op ventilator & Pediatric reconstruction facilities. Support services of Pediatrician

4 OphthalmologyQualified Ophthalmologist, trained vitreo Retinal and corneal surgeon Optometry facility

Well equipped theatre facility 5 ENTQualified ENT Surgeon Well equipped theatre Post-op with ventilator support Audiology support, furnish the audiologist name, qualification andinfrastructure available along with photograph of the equipment.

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No. SpecialtyPleaseTick

A. SURGICAL SPECIALTIES6 Cardio-thoracic surgery

CT Surgeon CT theatre facility CathlabCardiologist support Post-op with ventilator support ICCU Other cardiac infrastructure

7 Plastic SurgeryQualified Plastic Surgeon with Mch in plastic surgery or other equivalentdegree recognized by MCI

Well Equipped Theatre

SICU Post-op with ventilator support Trained ParamedicsPost-op rehab/ Physiotherapy support

8 NeurosurgeryQualified Neuro-Surgeon(M.Ch Neurosurgery /DNB Neurosurgery) Well Equipped Theatre with qualified paramedical staff, C-Arm,Microscope, neurosurgery compatible OT table with head holding frame(horse shoe, mayfield / sugita or equivalent frame).

Neuro ICU facility

Post-op with ventilator support Step down ICU facility Facilitation for round the clock MRI,CT and other support bio-chemicalinvestigations

9 UrologyQualified urologist Well equipped theatre with C-ARM Endoscopic investigation support Post-op with ventilator support Esw lithotripsy equipment

10 Pediatric SurgeryQualified pediatric surgeon Well equipped theatre Pediatric and Neonatal ICU support Post op with ventilator and pediatric resuscitator facility Support services of pediatrician

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No. SpecialtyPleaseTick

11 Surgical GastroenterologyQualified Surgical Gastroenterologist Well Equipped Theatre Endoscope equipment

Post op with ventilator support The hospital must have done at least 100 Endoscopic SurgeriesSICU

12 Burn UnitQualified Plastic Surgeon with Mch in plastic surgery or other equivalentdegree recognized by MCI.

Isolation wards having monitor, defibrillator, central oxygen line and allOT equipment.No touch method of wound dressing.Support of General Surgeon.

B. MEDICAL SPECIALTIES1 General Medicine

Qualified General Physician with post graduate degree in General Medicineor EqualAMC with ventilator support

2 PediatricsQualified pediatricianNICU & PICU fully equipped Round the clock Pediatric / Emergency service room with Pediatrician Pediatric resuscitation facility

3 Cardiology

Qualified Cardiologist with DM or Equivalent Degree ICU Facility with cardiac monitoring and ventilator support. Hospital should facilitate Round the clock cardiologist services. Availability of support specialty of General Physician,& Pediatrician

3a Cardiac Interventions and ProceduresQualified Cardiologist with experience in interventions and proceduresFully equipped Cathlab Unit with qualified and trained ParamedicsMust have Backup CT Surgery Unit to perform Cardiac SurgeriesThe hospital should have done at least 100 interventions

4 Nephrology

Qualified Nephrologists with DM or Equivalent Degree Haemodialysis facility AMC and Physician Support.

5 Medical-Gastro EnterologyQualified Gastro Enterologist with DM or Equivalent Degree. Endoscopy facility AMC and Physician Support. Center Must have done at least 100 Endoscopic Procedures

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No. Specialty Please Tick 6 Endocrinology

Qualified Endocrinologist with DM or Equivalent Degree. AMC with ventilator and Physician Support.7 Neurology

Qualified Neurologist with DM or Equivalent Degree. EEG, ENMG, Angio-CT facility for Neurological study. Neuro ICU Facility with ventilator support. Physician Support.

8 DermatologyQualified Dermatologist with MD or Equivalent Degree. AMC and Physician Support.

9 Pulmonology Qualified Pulmonologist RICU facility

Spirometry and Bronchoscopy facility Physician Support. 10 Rheumatology

Qualified RheumatologistMICU FacilityPhysician and Orthopaedic SupportPhysiotherapy Support

C.COMBINED SERVICES FOR CANCER THERAPY1 Cancer

Services of qualified Medical OncologistServices of qualified Surgical Oncologist

Services of qualified Radiation Oncologist Fully equipped Radiotherapy Unit SICU

3. The hospital should have well equipped operation theatre with following equipment: Boyles apparatus Endoscopes Monitor Diathermy Laparoscopic Equipment if necessary as per the specialty treatment catered. Operating Microscope if necessary as per the specialty treatment catered. Suction apparatus Pulse oxymeter Sterility unit and other equipment as per the specialties treatment available.

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4. The hospital should have following fully equipped diagnostic facilities:

The hospital shall facilitate free diagnostic facilities including advance diagnostic tests in-house oreither in the tied-up diagnostic centers, such as:

A. In house mandatory diagnostic facilities:

Radiology: X-Ray, USG and ECG. Biochemistry, Micro biology & Serology, Haematology.

B. Advance diagnostic tests in house /tie-up:

CT, MRI, ECHO, Pathology etc.,

Note: The hospital as well as tied up diagnostic centre shall furnish affidavit about extending freediagnostic tests for scheme members at tied up diagnostic centre.

5. The hospital shall have round the clock blood bank facility in house / tied up.

6. The hospital should have qualified anesthetist round the clock in house / on call.

7. The hospital shall maintain complete record on day to day basis and shall provide records of thepatient to Trust as and when it is required.

8. Thehospital shall ensure cashless facility to the scheme members as per the surgery packages devisedby the SAS Trust. The surgery package includes cost of consultation, medicine, diagnostics, implants,food, transportation charges, OT charges, Professional fees, hospitalization charges and follow uptreatment with medicines at least for one year, in other words the package includes entire cost oftreatment of patient from the date of admission to the date of discharge with follow-up treatment cost.

9. The hospital shall ensure free OPD consultations to all the beneficiaries.

10. The hospital shall ensure free diagnostic tests for all walk-in scheme members irrespective of thescheme members undergoing surgeries.

11. The hospital shall provide transportation charges to patients on actual basis.

12. The hospital should have sufficient experienced specialists / super specialists in the specificidentified fields (as per point no. 2) for which the hospital is empanelled

13. For extending the treatment of Chemotherapy and Radiotherapy the hospital should haveinfrastructure for Radiotherapy and full time Radiation Oncologist and Medical oncologist must beavailable.

14. The hospital shall furnish the chemotherapy drugs bills along with empty vials and quote the batchno. of the drugs with label intact.

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15. The hospital should have full time services of qualified plastic surgeon with requisite infrastructurefor corrective surgeries for post burn contractures.

16. The hospital should have round the clock in-house pharmacy.

17. The hospital should have full time services of pediatric surgeons / plastic surgeons / urologistsurgeons related to congenital malformations in pediatric age group (less than 14 years).

18. The hospital shall provide following additional facilities and benefits to the BPL patients:

a) Shall ensure exclusive health cell/kiosk for Suvarna Arogya Suraksha Scheme to enable theArogyamitra to execute his/her duties.

b) Shall provide a computer with networking (dedicated broad band with minimum 2 mbps speed),Printer, Scanner and digital camera.

c) Shall ensure a dedicated medical officer to work as medical coordinator for the scheme and he / shewill be responsible for various activities of the scheme such as health camps, follow up of referredpatients from camps, diagnosis, outpatient details, E-Preauthorisations, surgeries, feedback on thepatients condition and service offered by the hospital during hospitalization of the patient, discharges,deaths if any, free consultation for the follow up patients and distribution of medicines after dischargeetc.

d) Shall conduct minimum number of free health camps as stipulated in MoU for identifying andscreening of the BPL patients suffering from the identified ailments. The hospital shall have a mobileteam with diagnostic equipment and team of doctors as specified by the Trust for conducting health

camps purpose. The villages are identified by the Trust in consultation with district administration andcommunicated to the hospital.

19. MOU with Trust:

The hospital will be inspected by the Trust before empanelment. The Empanelment and DisciplinaryCommittee of the Trust will scrutinize the application, inspection reports and other material facts forempanelling the hospital. The provider complying with the criteria for empanelment is required to signMOU with the Trust.

20. Delisting and other disciplinary action: The Empanelment and Disciplinary Committee of theTrust will look in to all complaints and grievances received from the patients, field staffs, vigilance and

other inspection teams with regard to the quality of services and compliance with the MOU clauses andmay recommend disciplinary action including delisting of the hospital.

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empanelment application & criteria

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