hca form 2017 multi specialty - tertiary care...
TRANSCRIPT
Multi Specialty - Tertiary Care Hospitals
Greetings!
In an endeavor to present to the nation its finest healthcare providers, CNBC-TV18 and ICICI Lombard are initiating
the Healthcare Awards - India's most authoritative awards for the healthcare industry. Kantar IMRB, India’s leading
research agency is powering the robust multi-phase methodology that will help shortlist India's finest healthcare
providers. A panel of the most distinguished names in the industry and academia will then debate and deliberate to
select the final winners across categories.
Please fill the form below to apply into the first phase of the awards.
IMPORTANT: Please fill this form only if you are an authorized representative in the senior management team,
administrative head or PRO of the hospital. Please note, fill this form only if this is a Tertiary care hospital.
Your hospital needs to meet the following criteria to qualify:
Centre of excellence specialty
a. A hospital providing tertiary care in one or more specialties
b. Can be single or multi-specialty tertiary hospital
c. Private or government
d. Should be in operation for at least 3 years (i.e. since Aug 2014)
e. Bed size - any number
f. Should have a website
g. Can nominate up to 3 top specialties for which hospital can be considered
h. Hospital can be located in any city in India
Multi-specialty Tertiary care
a. Should be a multi-specialty tertiary care hospital
b. The hospital must provide specialized tertiary care (consultative and surgical care) in at least THREE
specialties
c. Have relevant medical and support infrastructure and super-specialists in the tertiary care disciplines
d. Private or government
e. Should be in operation for 3 years (i.e. since Aug 2014)
f. Bed size – at least 100 bedded
g. Should have a website
h. Hospital can be located in any city in India
o Cardiology o Oncology o Neurology o Ophthalmology o Nephrology & Urology o Pediatrics
o Orthopedics o Gastroenterology & General surgery o Gynecology & IVF o Diabetes / Endocrinology
o Single specialty - center of excellence - {Specify Specialty (you can nominate up to 3 top specialties)}
1.............................................................................................................................................................................
2.............................................................................................................................................................................
3.............................................................................................................................................................................
o Multi-Specialty (if hospital provides tertiary care in at least 3 specialties)
Last date to submit the form is 15th Dec. 2017
Please Mark the specialties for which Tertiary care services are offered in the hospital from the list given
Please SELECT the award/awards category that you would like to nominate the hospital for:
1. Please fill out the following details about yourself.
2. Please fill out the following details about your hospital.
3. The following table contains a list of parameters regarding hospital capacity. Please fill in the grid
below :
4. Please place a TICK in the box if your hospital has the following diagnostic and Imaging services.
5. Please place a TICK in the box if your hospital has the following laboratory services
Name .........................................................................................................................................................................
Designation ................................................................................................................................................................
Email ID ......................................................................................................................................................................
Telephone .................................................................. Mobile ....................................................................................
Years worked at current hospital ...................................................... Total years of experience ...................................
Name of the hospital ...................................................................................................................................................
Year of inception of hospital ........................................................................................................................................
Address 1 ...................................................................................................................................................................
Address 2 ...................................................................................................................................................................
Nearest landmark.......................................................................................................................................................
City ....................................................... State........................................................... Pin Code ..................................
Website ......................................................................................................................................................................
Hospital type: (Please TICK relevant option): Teaching Non-Teaching
Hospital ownership/legal status: (Please TICK relevant option):
o State Government o Central Government o PSU Unit (ESI / Railways / Defense)
o Proprietorship o Partnership o Private Ltd Firm o Trust / co-operative o Public Ltd firm
Accreditation for hospital: (Please TICK relevant option(s)): o NABH o JCI o ISO
o Other (specify):.......................................................................................................................................................
Accreditation for lab: (Please TICK relevant option(s)): o NABH
o Other (specify):.......................................................................................................................................................
Number of beds in private rooms ..................... Number of functional beds in general wards .....................
Number of functional beds in special wards ..................... Number of Dialysis beds .....................
Number of functional beds in Emergency wards ..................... Number of free cost beds .....................
Number of functional beds in ICUs / SICUs / NICUs .....................
Beds - TOTAL (sum of all the above) .................................
% Occupancy of beds (in the last one year)
Number of General wards ..................... Number of Special wards .....................
Number of Emergency Wards ..................... Number of ICU / SICU / NICU .....................
Number of Labour Rooms (only for Gynecology & Obstetrics) .....................
Total Number of Operation theatres ..................... Number of minor Operation Theatres .....................
Number of major Operation Theatres .....................
Diagnostic & Imaging services:
o 2D ECHO o Bone Densitometry o CT scanning o Cathlab /DSA o ECG o EEG o EMG/EP
o Endoscopy o Audiometry o Holter monitoring o Mammography o MRI o G-Scan/ Open MRI
o CRRT (Continuous Renal Replacement Therapy) o IMRT (Intensity-modulated radiation therapy)
o IGRT (Image Guided Radiation Therapy) o SRS (Stereotactic Radiosurgery) o Spirometry o ECMO
o Tread mill testing o Ultrasound/Sonography o Urodynamic studies o PET Scan o Radio Immuno Assay
o Picture Archival & communication systems (PACS)
o Others..................................................................................................................................................................................
Laboratory Services
o Clinical microbiology and serology o Clinical biochemistry o Clinical Pathology o Cythopathology
o Haemotology o Histopathology
o Other (please list below).........................................................................................................................................
o o
6. Please place a TICK in the box if your hospital has the following support services
7. How many patients does your hospital treat across all departments in a typical ONE-MONTH period?
Please fill in the information as on August 2017 in the blank space on the right :
8. Information on doctors/specialists :
9. Information on super specialist doctors and surgeons working. Break-up by Specialties.
10. Information on other hospital staff :
11. Please list the specialties and the high-end / major surgery volumes last month (Aug 2017)
Support Services
o International patients help desk o Cafeteria/Canteen o Catering for in-patients o Insurance Desk
o Pharmacy inside hospital o Ambulance Service o Bio-medical Engineering unit o Blood bank
o Human Resources Department o Information Technology Department o Laundry management
o Maintenance & Facilities management like housekeeping etc. o Management of Bio-medical waste
o Mortuary Services o 24 hour Security o Social Service / outreach activities o IVF facility
o Supply Chain Management / Material Management system o Nutrition & Dietetics
o Online appointments o Online consulting/ telemedicine o Online payments o Pneumatic Chutes
o Parking facility within hospital premises which can park _____ (specify) car equivalents
o Other (please list below).........................................................................................................................................
OPD Capacity per day ..................... No. of patients treated free of cost in OPD .....................
No. of Outpatients (Non-admitted patients) ..................... No. of Admitted patients (in-patients) .....................
No of emergency cases admitted ..................... No. of admitted patients treated free of cost .....................
No. of International patients .....................
Total number of doctors/specialists (include total number of full-time/Part-Time/ visiting doctors) .....................
Place Mark against specialties offered Nos of specialists with DM / M. Ch or equivalent
super specialty qualifications
o Cardiology
o Neurology
o Nephrology & Urology
o Orthopedics
o Gynecology & IVF
o Diabetes
o Oncology
o Ophthalmology
o Pediatrics
o Gastroenterology & General surgery
o Diabetes & Endocrinology
Graduate Nurses ..................... Non-Graduate Nurses ..................... Technicians / Engineers .....................
Other paramedics ( Pharmacy/ Lab/ Imaging/ Bio-med / OT Staff etc ) .....................
Managerial / Administration / Accounts / HR / Marketing Legal etc. ..................... Housekeeping .....................
Other (please list below).........................................................................................................................................
Specialty Nos of Major surgeries / procedures performed (AUG ’17)
o Cardiology
o Neurology
o Nephrology & Urology
o Orthopedics
o Gastroenterology & General surgery
o Oncology
o Ophthalmology
o Gynecology & IVF
o Pediatrics
o Diabetes & Endocrinology
12. Please provide the volumes of a few specialized surgeries list in the table below.
13. Please place a TICK against the activity in which your hospital is involved
14. Please list any Awards or recognition your hospital has won in the last 2 years
15. Please provide a list of senior doctors who head the top 3 specialty departments attached to your
hospital with their contact information in the grid below
Specialty Specialized surgeries Numbers last month
Cardiology / Cardiothoracic • Bypass surgeries (CABG)
surgery / Cardiac Interventions • Valve replacements
Orthopedics • Joint replacements
Nephrology and Urology • Renal transplants
• TURP (Transurethral resection of the prostate)
Oncology • Radiation Onco-surgeries
• Surgical Onco-surgeries
General Surgery / • Liver Transplants
Gastroenterology / Liver • Gastric bypass
• Hepato-pancreatico-biliary (HPB) Surgery
• Bariatric surgeries
• Cosmetic surgeries
Gynecology & IVF • IVF patients treated
• Lap Hysterectomy
Neurosciences, Neurology, • Deep Brain Stimulation Surgery
Bone and Spine • Laminectomy (Lumbar/Cervical)
Pediatrics • Pediatric Surgeries
Ophthalmology • Corneal transplants
Activities involved in
o Clinical Trials of new drugs o Experimental surgery o Facility / Lab for Research & Development
o Disease Management Programmes o Health Promotion and Counseling services
o Disability certification services
Name of Accreditation / Award won Year
Specialty Name of doctor – Head of department Contact Doctor’s Qualification
Please send in your completed form to:
Ms. Chhaya Jadhav, TV18 Broadcast Ltd., Empire Complex, 1st Floor 414, Senapati Bapat Marg, Lower Parel, Mumbai 13.
Contact - email us at [email protected] or log on to www.firstpost.com/ihcwa
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