Government of Karnataka
SUVARNA AROGYA SURAKSHA TRUST
(Department of Health & Family Welfare)
Bangalore Metropolitan Transport Corporation, TTMC “A” Block,
4th Floor, Shanthinagar, K.H. Road, Bangalore-560 027,
Phone: 080-22536200, Fax: 080-22536221 E-mail: directorsast@gmail.com
Network Hospital Renewal Proforma
Please fill in the information in this format and submit your proposal for renewal for another
period of one year as Network hospital under VAS/JSS/RAB/RBSK Scheme along with D.D. for Rs.
____________/-
(In
words
______________________________),
_____________________________,
Bank
:
DD
No.
_____________________________
&
Date
Branch
:
_______________________ only in the name of Executive Director, Suvarna Arogya Suraksha
Trust, Bangalore.
Date:
Background information
Hospital Name & Address
Names of SAMCO & Ph No
Phone No. and mail ID
Contact Person
Accredited
NABH Accreditation Status
Applied
Not started
If not, when do you plan to apply?
Other accreditations if any like NABL,
Safe –I, ISO certifications etc.,
Any other government special scheme
empaneled
Yes / No
1) RSBY
Specify Other schemes
2) Yeshasvini
1)
3) ESI
Names of Arogyamitra & Ph No
2)
4) CGHS
1
Empanelment history
Date of first empanelment
Facility ownership
Renewal dates :
1)
/
/
2)
/
/
3)
/
/
4)
/
/
5)
/
/
Public
Private
Teaching medical college
charitable trust
Facility Level
Single specialty
Multi specialty
Any request for new
specialty/specialties
Cardiology & Cardiothoracic Surgery
Urology
Neurosurgery
Neonatal & Pediatric Surgery
Polytrauma
Burns
Oncology (Surgical, Radiation & Chemotherapy)
Infrastructure as declared by the hospital to be reviewed for different specialties
Super specialty Bed strength (General Ward)
Total available and allotted to SAST
TOTAL
VAS
JSS
RAB
Available Allocated Available Allocated Available Allocated
2
RBSK
Available Allocated
Specialties empanelled
Bed strength
specialty wise
Specialties empanelled
Cardiology
Neonatal & Pediatric Surgery
Cardiothoracic Surgery
Polytrauma
Urology
Burns
Neurosurgery
Oncology (Surgical, Radiation
& Chemotherapy)
Bed strength
specialty wise
Specialties for which facilities
are available, but empanelment
not done
The hospital should have at least 50 beds
A. General Ward beds (Total):
Declared by
Hospital
1. 1 Nurse
YES/NO
2. 1 duty doctor
YES/NO
3. The space between two beds should be at
YES/NO
least 5 feet.
4. The provider should have separate male and
YES/NO
female wards.
No of ICU Beds available in the hospital:
1. At least 3 beds
YES/NO
2. 1 Nurse
YES/NO
3. 1 duty doctor
YES/NO
The ICU ward should be equipped with
1. Monitors, central oxygen line,
YES/NO
2. Suction apparatus
YES/NO
3. Pulse oxymeter
YES/NO
4. Ventilators (including portable)
YES/NO
(consist of a flexible breathing circuit, gas supply,
heating/humidification mechanism, monitors, and
alarms)
5. 3/5 lead ECG
YES/NO
6. Infusion pump
YES/NO
7. Ambu bags
YES/NO
8. Central venous line catheters
YES/NO
9. Endo tracheal tubes of all sizes
YES/NO
10. Crash cart—also called a resuscitation cart
YES/NO
3
Comments by inspection team
11. Chest tubes
YES/NO
12. Gastric tubes
YES/NO
13. Foleys catheter
YES/NO
14. Tracheostomy set
YES/NO
No. of Step down ICU ward:
1. At least 2 beds
YES/NO
2. 1 Nurse
YES/NO
3. 1 duty doctor.
YES/NO
The step down ICU ward should be equipped with
1.
Defibrillators
YES/NO
2.
Monitors
YES/NO
3.
Central oxygen line
YES/NO
4.
Suction apparatus
YES/NO
5.
Pulse oxymeter.
YES/NO
No. of post operative ward:
1. At least 2 beds
YES/NO
2. 1 Nurse
YES/NO
3. 1 duty doctor
YES/NO
The post operative ward should be equipped with
1.
Ventilators
YES/NO
2.
Defibrillators
YES/NO
3.
Monitors
YES/NO
4.
Central oxygen line
YES/NO
5.
Suction apparatus
YES/NO
6.
Pulse oxymeter
YES/NO
Tie-ups - MOUs with other facilities- copy of MOU to be enclosed
To be checked by the inspection team
Diagnostics
Oncology

Radiology

Radiation Oncology

Lab Services

Medical Oncology

Blood bank

Surgical Oncology
4
Any addition or deletion made to, infrastructure. If so mention in brief, compared to last year
empanelment.
Specialty- Equipment's which are critical for particular specialty available or not as per SAST guidelines
Cardiology & Cardio-thoracic surgery
Cardiac OT
Yes / No
Cathlab
Cardiologist support
Yes / No
Yes / No
Post-op with ventilator support
Yes / No
ICCU
Yes / No
Other cardiac infrastructure (Monitors, infusion pumps)
Neuro Surgery
Well Equipped Theatre with qualified paramedical staff, CArm, Microscope, neurosurgery compatible OT table with head
holding frame (horse shoe, may field / sugita or equivalent
frame).
Neuro ICU facility
Yes / No
Post-op with ventilator support
Yes / No
Step down ICU facility
Yes / No
Facilitation for round the clock MRI,CT and other support biochemical investigations
Urology
Well equipped theatre with C-ARM
Yes / No
Endoscopic investigation support
Yes / No
Post-op with ventilator support
Yes / No
ESW lithotripsy equipment
Yes / No
Yes / No
Yes / No
Yes / No
Burns
Well Equipped Theatre
Yes / No
Surgical Intensive Care Unit
Yes / No
Post-op with ventilator support
Yes / No
Trained Paramedics
Yes / No
5
Post-op rehab/ Physiotherapy support
Isolation wards having monitor, defibrillator, central oxygen
line and all OT equipment.
No touch method of wound dressing.
Yes / No
Yes / No
Support of General Surgeon.
Yes / No
Yes / No
Neonatal/Pediatric Surgery
NICU (Neonatal Intensive Care Unit) & PICU (Paediatric Yes / No
intensive Care Unit) fully equipped
Round the clock Pediatric / Emergency service room with Yes / No
Pediatrician
Pediatric resuscitation facility
Yes / No
Well equipped theatre
Yes / No
Post op with ventilator and pediatric resuscitator facility
Yes / No
Oncology
Services of qualified Medical Oncologist
Yes / No
Services of qualified Surgical Oncologist
Yes / No
Services of qualified Radiation Oncologist
Yes / No
Fully equipped Radiotherapy Unit
Yes / No
SICU(Surgical Intensive Care Unit)
Yes / No
Well Equipped Theatre
Yes / No
Endoscope equipment
Yes / No
Post op with ventilator support
Yes / No
Polytrauma
Well equipped theatre with C-Arm facility
Yes / No
Trained paramedics
Yes / No
Well equipped Post-op facility with Ventilator Support
Yes / No
Round the clock lab support with CT,MRI
Yes / No
The hospital should have well equipped OPERATION THEATRE with following equipment
1. T3/5 lead ECG
Yes / No
2. Defibrillator
Yes / No
3. Boyle’s apparatus
Yes / No
4. Endoscopes
Yes / No
5. Monitor
Yes / No
6. Diathermy
Yes / No
6
7. Laparoscopic Equipment if necessary as per the specialty Yes / No
treatment catered
8. Operating Microscope if necessary as per the specialty Yes / No
treatment catered
9. Suction apparatus
Yes / No
10. Pulse oxymeter
Yes / No
11. Sterility unit and other equipment as per the specialties Yes / No
treatment available.
12. Anesthetists
Round the clock / In house / On call
13. Pharmacy (round the clock)
Yes / No
14. Ambulance
Yes / No
15. Food services
Yes / No
Provide the names of existing empanelled Super Specialist Doctors with their qualifications and KMC
Registration No.s & Ph. No.s (Fill in Annexure – IA & IB)
Any empanelled super specialist Doctors who have left the
hospital since previous renewal– Details
Hospital performance in the last year:
No of pre-authorizations for all
schemes
Number of patients treated in your
hospital (specialty wise).
Cardiology
Submitted
Approved
Denied
Cancelled
VAS
JSS
RAB
RBSK
1) Cardiothoracic &
Vascular Surgery
Neuro Surgery
Urology
Neonatal & Peadiatric Surgery
Polytrauma
7
Burns
Oncology (Surgical, Radiation &
Chemotherapy)
No: submitted
Claims
Please provide information about
follow-up cases.
No: approved
No: denied
Provide information specialty wise :
Cardiology
No. of Cases
___________________________
:
Cardiothoracic Surgery
___________________________
Urology
________________ __________
Neurosurgery
________________ __________
Amount claimed :
Mortality figures
During hospitalization
Details of mortality
Sentinel Events*
VAS
JSS
RAB
RBSK
(Fill in Annexure-II)
VAS
JSS
RAB
RBSK
During
hospitalization
Details Sentinel event
Name of Patient
Original diagnosis
Sentinel event
No. of camps
Allotted
______________
Attended
______________
Screened
______________
treated in the past year ______________
* Any unintended complications during the procedure/stay of the beneficiary which caused serious injury/
consequence
Have you submitted the Questionnaire for self assessment of Mortality/ Morbidity and infection Completed : Yes/No
control Practices in the Hospital
Kindly fill the below questionnaire (if not submitted)
8
Questionnaire
Review Infection Control Practices in the Hospital
Instructions:



Please fill in the accurate details in the provided space
For Questions having option of yes and no, please tick mark
Describe the answer where-ever asked
General Questionnaire
Q-1.Do you have an Infection
Committee in your Hospital?
Control Yes
No
If yes, please answer Q-2, if no; please go to Q-3
Q-2. Who all are the members of the Infection Control Committee? (First name of the member
secretary/chairman of the committee)
Name
Designation
If No,
Q-3. What is the plan of the management for constituting the Infection Control Committee and time
frame required?
Q-4. How frequently the Committee conducts its meeting? (Tick mark whichever applicable)
Once in a month
Once in 6 months
Yearly
9
Others (Specify)
Q-5. What are the selection criteria for the hospital acquired infection cases to be discussed?
Q-6. How frequently the training program on infection control related parameters are conducted for
the medical and the paramedical staff? (Tick mark whichever applicable)
Every 6 months
Yearly
Others (specify)
Q-7. What types of infections specific to your hospitals are observed and its rates?
Type of Infection
Yes
No
Ventilation Associated Pneumonia
Rate if Yes
Central Line Associated Blood Stream Infection
Surgical Site infection
Catheter association UTI
Others (Specify)
Q-8. How are the records maintained?
Q-9. Does the hospital have anti-biogram policy Yes
on the use of the antibiotics?
No
Q- 10. Has the audits been conducted in the hospital helped to improve the infection control practices?
10
Questionnaire to assess
Mortality/Morbidity Practices in the Hospital
Q-1. Does the hospital have the Mortality/Morbidity Committee?
(Please tick mark)
Yes / No
If Yes
Q-2. Who all are the members of the Committee? (First name of the member secretary/chairman of the
committee)
Name
Designation
Q-3. What is the plan of the management to constitute Mortality/Morbidity Committee and time frame
required?
Q-4. How frequently the Committee conducts the meeting? (Please tick Mark)
Once in a month
Once in six months
Once in a year
Others (Specify)
Q-5. What are the selection criteria for cases to be discussed in the meeting?
Q-6. How frequently the Mortality/Morbidity Audits are conducted? (Please tick Mark)
Once in a quarter
Once in six months
Once in a Year
Others (Specify)
Q-7. Have there been any instances wherein this process has helped to improve the services
provided/Mortality Index?
11
Q-8. How are the mortality records maintained? (Please tick Mark)
Hard copies
Soft Copy (HIMS)
Others (Specify)
NOTE: Please share copies of last 3 mortality audits conducted in your hospital
I confirm that the information provided above is true to the best of my knowledge and belief. In
case, the information furnished above is proved to be false subsequently, SAST is hereby
authorized to delete our hospital from the list of Network hospitals under SAST.
Authorised Senior Person Name :
Seal & Signature :
Designation :
Date :
12
Annexure-IA
In house (Full time)
Sl
Doctors Name
Speciality
1
2
3
4
5
6
7
8
9
10
11
12
13
KMC Reg. No.
Ph No.
Annexure-IB
Visiting / On-call
Sl
Doctors Name
Speciality
1
2
3
4
5
6
7
8
9
10
11
12
14
KMC Reg. No.
Ph No.
Annexure-II
1
Name of Patient
Original diagnosis
2
Name of Patient
3
Name of Patient
3
Name of Patient
Cause of death
15
4
Name of Patient
Original diagnosis
Cause of death
5
6
7
16
Salient points to consider during Hospital visit
(Will be filled by the inspection team)
Check Regulatory licenses
(Copy to be enclosed for all those that are
applicable to your hospital)
Organization registration
Renewals
KPME
Pollution control
AERB
AERB Compliance reports
AERB inspection records
AMC for RT machine
Bio Medical Waste management support
Pharmacy
Lab accreditation
Blood bank license
Facility inspection
OT
ICUs
Wards
CSSD
Labs
X-ray
USG
RT
CT facilities
Other
Random document Review
(Manual/computerised)
Admission registers maintained
Lab registers
RT planning charts
Patient case sheet
Discharge register
Death Register
Other
OT register
OT maintenance register
17
Kiosk Assessment
Have you established the KIOSK as per SAST
guidelines
Yes / No
If yes- Please Enclose photograph of the KIOSK
Presence
Strategic location
Well equipped
If no – please explain why you have not established the
kiosk yet as per new guidelines?
Arogyamitra Interaction
To check if she has independent access to :
Computers
Internet
Camera
Printer
Scanner
Pen drive
Stationaries
Discuss any issues with Arogyamitra
Interaction with SAMCO and Hospital staff
Discuss any issues involved in implementation of the scheme/objections
18
Beneficiary visit
Check whether AM visits regularly
Beneficiary in the same ward as the speciality for
Pre- auth approved(For eg: Paediatric patients for burns in
Ophthalmic ward)
Any complaints
Medical care
Amount paid
Food provided
Overall satisfaction
Any showcause notices/ temporary suspension of
empanelment done for your hospital?
Yes/No
If yes specify ________________
Inspection comments
Any previous inspection reports / Hospital
visit reports
Detailed comments
Remarks of the inspection team
Consider for continuation of empanelment
Yes/NO
19
Name:
Date:
Signature:
Name:
Date:
Signature:
Name:
Date:
Signature:
20