PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
Initial Assessment Form
Do you have any certification if yes, please mention below?
Yes No
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________
What certification you want to get?
Accreditation Entry level SHCOs Certification
Accreditation Entry Level Hospitals Certification
NABH full standards
ISO Certification
Medical Lab Standards
Blood Bank standards
MIS standards
EMS standards
Nursing excellence
Add Another if any:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________
Contact Details of Hospital
Name of the Hospital: _______________________________________
Address:_____________________________________________________________________________
________________________________________________________________________________
Country: ____________ State: _____________ City: _______________ Pin: ________________
Does the hospital have split locations?
Yes No
1
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
Address:_____________________________________________________________________________
________________________________________________________________________________
Ownership/ Legal Identity:
Private – Corporate
Trust
Charitable
PSU
Government
Other
Date of establishment and registration: ______________
Year in which Clinical Function started: _______________
Registered under which Authority (as per central requirements):
1)________________________________________________________________________________2)_
_______________________________________________________________________________3)___
_____________________________________________________________________________4)_____
__________________________________________________________________________
Contact Details:
Top Management in the Hospital:
Salutation (Mr./Ms./Mrs./Dr./PhD) __________________________
First Name ____________________________________________
Middle Name __________________________________________
Last Name __________________________
Designation __________________________
Email Id: __________________________
Telephone _________________ Mobile ______________________Fax: _______________
Quality /Accreditation Coordinator
Salutation (Mr./Ms./Mrs./Dr./PhD) __________________________
First Name ____________________________________________
Middle Name __________________________________________
Last Name __________________________
Designation __________________________
Email Id: __________________________
Telephone _________________ Mobile ______________________Fax: _______________
Are you using or used any consultant to assist you for the Accreditation Process? (Yes/No).
2
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
________________________________________________________________________
Do you Committees in your Organisation (Yes/No):
Quality Committee
Safety Committee
OT Committee
HOD Committee
ICU Committee
Staff Committee
Ethics Committee
Infection Control Committee
Sexual Harassment Committee
Pharmacy & Therapeutic Committee
Morbidity & Mortality Committee
Information Management Committee
Credential & Privilege Committee
Material Management Committee
Radiation safety Committee
Do you have In-Service training Schedule (Yes/No)?
Induction program
Personality development
Grooming at work
Stress management
Fire safety training and evacuation plan
Management of chemical spill
Disaster management
Medical records Audit
Care of invasive lines
Inventory management
Crash cart Monitoring
Bed side care procedures
IV-line insertion
Invasive lines insertion and maintenance
End of life care
Care of wounds and wound dressing
Bed sore prevention and maintenance
3
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
Restraints policy
Care of vulnerable patients
Role of Nurse in Hospital Quality assurance
Prevention of patient Falls
Thrombophlebitis
HAIs
Burns
Bed sores
Care and maintenance of Invasive
Management of Medication
Rights of Medication Administration
Safe preparation and transportation of Chemotherapeutic agents
Medication safely
Cold chain maintenance
Storage and use of High alert medications
Narcotics and Concentrated Electrolytes
Introduction to Infection control
High Risk areas and procedures in the hospital
Hand Hygiene
Appropriate use of PPEs and Standard Precautions
Disinfection
Sterilization and Disinfectant use
BMW management
Isolation Precautions & Spill Management
Needle Stick Injury
PEP
Hospital acquired infections Surveillance & Monitoring
Care Bundles & Infection control Guidelines in ICU
OT
Linen Management
Mortuary & Kitchen
Microbiology Sample Collection
Use of multidose vials
Recall policy
Hospital Bed Details
4
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
Total Number of Beds that have been sanctioned*: ____________
Total Number of Beds currently in operation*: ____________
# Bed Type Number of Beds
1 In-patient Beds (non-ICU) *
2 In-patient Beds(ICU)*
3 Emergency Beds
4 Day-care Beds
5 Recovery room Beds
6 Labour room beds
7 Dialysis
8 Other*
Number of OTs*: ____________
Super-speciality:
EMERGENCY OT GENERAL OT ORTHO OT CARDIAC OT
OBS&GYNAC OT SEPTIC OT TRANSPLANT OT EYE & ENT OT
NEURO OT ONCO OT
Layout of the Hospital:
Number of buildings: _________ Wing: _________
Area in square feet as per Agreement*: _________
Location on which floor: _________
Available/Not Available
# Services (Yes/No) Number of Availability
1 General Lifts
2 Patient Lifts
3 Service Lifts
4 BMW collection room
5 RO water Supply
6 PA System
7 Parking space
5
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
Available/Not Available
# Services (Yes/No) Number of Availability
8 Other*
List of Fire Safety Equipment
Available/Not
Available Number of Safety
# Services (Yes/No) Equipment
1 Fire Sprinklers and Fire
censors
2 Fire Control Panel
3 Fire Hydrant
4 Fire Blankets
5 Fire Extinguishers
6 Hose reel
7 Other*
Do you have Department Wise SOPs for the following?
Available/Not Available
Serial # Policies (Yes/No)
1 Clinical SOPs/Process Flows/Policies
2 Organisational Process/Organogram/Policies
3 Patient Access Policies
4 Employee Safety
5 Other*
6
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
Departmental Manuals
Serial # Manuals Available/Not Available (Yes/No)
1 Apex Manual
2 HIC Manual
3 Lab Manual
4 CSSD Manual
5 OT Manual
6 Radiation Manual
7 Safety Manual
8 ICU Manual
9 House keeping
10 Other*
Emergency Codes
Serial Available/Not
# Code Department Available (Yes/No)
1 Code Blue Medical Emergency
2 Paediatric Code Paediatric Medical Emergency
Blue
3 Code Red Fire
4 Code Pink Child abduction
5 Code Black Internal Disaster Bomb threat/ Blast
6 Code Purple Physical Assault
7 Code Grey External Disaster (Accident,
Earthquake, Riots)
8 Code HAZMAT Chemical Spill (more than 30 ml)
9 Other*
Clinical Services and Related Details
7
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
OPD Data Past 1 years OR Average Occupancy Rate (%)*: _______________
Total number of inpatient days for a given period*: _______________
Number of Available beds days in the period*: _______________
IPD Data Past 1-year*: _______________
Scope of Certification Table
# Speciality Service Average daily Average daily in Number of
Provide Out patients patients during Consultant
d (Yes/ during the the Previous s
No) Previous Calendar Year
Calendar
1 Anaesthesiology
2 Burns unit
3 Critical care unit
(Combined)
4 Critical care unit
(General
Speciality)
5 Maternal and Chid
6 Dermatology &
Venereology
7 Dentistry
8 Emergency
Medicine
9 Family Medicine
10 General Medicine
11 Geriatrics
12 General Surgery
13 Obstetrics &
Gynaecology
14 Ophthalmology
8
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
15 Orthopaedic
surgery*
16 Otorhinolaryngolog
y
17 Paediatrics
18 Psychiatry
19 Respiratory
medicine
20 Sports medicine
21 Day care services
22 Transplant & Joint
Replacement
23 Other*
List of services
Serial Available/Not In House/ Out
# Services Name Available (Yes/No) source
1 Ambulance
2 Blood Bank / transfusion services
3 Dietetics
4 Psychology
5 Rehabilitation
6 Occupational Therapy
7 Physiotherapy
8 Speech and Language Therapy
9 Bone Densitometry
10 CT Scanning
11 DSA Lab
12 Gamma Camera
13 Mammography
14 MRI
9
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
Serial Available/Not In House/ Out
# Services Name Available (Yes/No) source
15 PET
16 Ultrasound
17 X-Ray
18 Clinical Bio-chemistry
19 Clinical Microbiology and
Serology
20 Clinical Pathology
21 Cytopathology
22 Genetics
23 Haematology
24 Histopathology
25 Molecular Biology
26 Toxicology
27 2D Echo
28 Audiometry
29 EEG
30 EMG/EP
31 Holter Monitoring
32 Spirometry
33 Tread Mill Testing
34 Urodynamic Studies
35 Bio-medical Engineering
36 Catering and Kitchen services
37 CSSD
38 General Administration
39 Housekeeping
40 Human Resources
41 Information Technology
42 Laundry
43 Maintenance/Facility
Management
44 Management of Bio-medical
Waste
45 Mortuary Services
10
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
Serial Available/Not In House/ Out
# Services Name Available (Yes/No) source
46 Pharmacy
47 Security
48 Community Service
49 Supply Chain Management/
Material
50 Management
51 Other*
Ward Information
List Ambulatory unit / Inpatient Care Units/ Wards, the Number and The type of care given in
each Unit/ Ward
Name of Unit/ Ward Number of beds Type of Care Staff/patient Ratio
Adult Male
Adult Female
Neonatal Male
Neonatal Female
Podiatric Male
Podiatric Female
Adult Male
Adult Female
Neonatal Male
Neonatal Female
Podiatric Male
Podiatric Female
Adult Male
Adult Female
Neonatal Male
Neonatal Female
Podiatric Male
Podiatric Female
Staff Information
# Group Number Education Registered with (MC/ Enter
Qualificatio NC/UGC/AICTE) (Yes/ Registration
n No) Number
11
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
1 Managerial
2 Resident
Doctors
3 Medical
Officer
4 Full Time
Consultant
5 Part Time
Consultant
6 Another
Consultant
7 Allied Medical
8 Speciality
Staff
9 Nurses
10 Technicians
11 Housekeeping
Staff
12 Other*
Statutory Compliances
# License/Certificate Available/Not Enter Issue Remarks
Available (Yes / Registration Date & (Please
No) Number Expiry mention if
Date any
licenses
are
pending
and how it
is being
addressed)
1 Bio-medical Waste
management and
Handling Authorization
12
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
2 Registration Under
Clinical Establishment
Act (or Similar)
3 OC for Building
4 Registration with Local
Authorities
5 NOC from Pollution
Control Board for
water, noise, air
pollution
6 Fire (NOC)
7 License for Diesel
Storage
8 License to Store
Compressed Gas
9 Registration for Boiler
10 Sanction / License for
Lifts
11 Registration for
Modality
12 License to operate
(CT/Interventional
Radiology (IR)
13 RSO
14 Registration for PNDT
15 Blood Bank
16 License for MTP
17 Drugs-Bulk license
18 Drugs-Retail license
19 Narcotic License
13
PCG-RKCA MANAGEMENT AND FINANCIAL SERVICES PVT LTD
20 Canteen / F & B
License
21 License for Possession
and Use of Methylated
Spirit, Denatured spirit
and Methyl alcohol
22 License for Possession
of Rectified Spirit &
ENA
23 Other*
Litigation & Self-assessment
If yes please Enter litigation:
____________________________________________________________________________________
____________________________________________________________________________________
______________________________________________________________________________
Weather Self-assessment done earlier (if any attach the report):
____________________________________________________________________________________
____________________________________________________________________________________
______________________________________________________________________________
14
