FICCI 8 th Annual Healthcare Excellence Awards Application form

Transcription

1 Eligibility Criteria: Any organization participating in the Awards should be an Indian entity with a registered presence in India. The Initiative should be completely executed in the Indian operations of the participant Organization must have at least 2 years of registered presence and operations in India as on March 31, 2016 The Awards shall be given to the initiatives in the healthcare sector for the period April 1, 2015 to March 31, 2016 Participating organizations must be engaged primarily in providing health care services. Nursing homes, dispensaries, day care facilities and non-allopathic facilities cannot apply. Participation is restricted to organizations subscribing to the allopathic system of medicine only Employees and immediate family members of the award management, sponsors and partners of the awards are not allowed to participate in the Awards Participation in the awards is subject to defined rules and regulations available on website Instructions for completing this Online Forms should be filled in English only. All mandatory questions (symbolised by *) must be answered. Incomplete forms or forms with incomplete sections may not be considered. A participating organisation can send entries in more than one award category or apply a maximum of two times in the same category provided it is for a separate project / initiative. Each project/initiative would need a separate online application form to be filled. One form cannot be used for multiple projects / initiatives. Please maintain one copy of the completed form with you for your records Please provide up to 5 supporting documents wherever possible, to support your entry details. Supporting documents have to be in the following formats only pdf, doc, jpeg etc. Size of each document cannot exceed 2 MB. Agreed Declaration by the Authorised person of the organisation is mandatory If you have any questions, or require any clarifications, please contact Mr Kapil Chadha on / 445 or write to us on kapil.chadha@ficci.com; anirudh.sen@ficci.com List of Documents Mandatory Document (These documents are mandatory to provide. Unavailability of these documents may result in disqualification of the participant) Copy of certification mentioned in the form Additional Documents (These documents are not mandatory; however, participants can provide them to support their application and claims) Please note: Additional documents submitted should be relating to the project / initiative submitted for review. Any other document will be disqualified and will not be submitted to the Jury for review. Project report with budgets and approvals Reports to evidence measurable impact Current year Annual report Awards, certifications, accolades etc Brochures, write ups, presentations, booklets, references Any other information you would like to highlight

2 Section 1 Participant Information FICCI 8 th Annual Healthcare Excellence Awards Name of participating entity * Name of Corporate or Group, Parent company or Trust If part of a Corporate or Group or Parent company or Trust to which the participating entity belongs Number of centres / branches / offices Number of city(s) with presence * Contact person * Name: Contact: Address of registered office in India * Year of incorporation * Revenue (Rs. in crores) * More than Less than o Single speciality (Hospital in which a single speciality accounts for more than 70% of the total patients (or in-patients where in-patient facilities are available) If yes, Speciality:, % of Revenue contribution: o Multispecialty hospital (Hospital which provides 5 basic specialities and having more than 50 beds) If yes, Total beds, Specialities & Revenue contribution o Small healthcare organization - Private(Hospital with less than 50 beds) o Small healthcare organization-public (Hospital with less than 50 beds, Sub-district hospital-category1) o Public (Hospital with more than 50 beds, District hospital/ Sub-district hospital-category 2) o Insurance Company (providing health insurance) o Organization (providing healthcare related products/services etc.) o Others - Specify Section 2 Category Selection Choose an item. Summary Innovation A) Name of Project / Initiative/Innovation *(max 25 words) B) If your innovation is patented, please provide the number (Applicable especially for category Innovation in Medical Technology and Disruptor of the Year)

3 C) Provide names of two other initiatives similar to yours (up to 2 names) (max 50 words) D) Describe 3 unique aspects of your project/initiative/innovation (max 75words) * E) Specify revenue growth or units sold in 2015 (Max 25 words) * F) Types of stakeholder and number of people benefitted (max 25 words) * G) How can this project/initiative/innovation be scaled up (max 25 words) * H) Why should your project/initiative/innovation win this award (max 75 word) * Section 3 Operational Metrics (Not applicable if the participant is not a healthcare institute) Total (Census beds) Top level parameters ICUs (Intensive Care Units) HDUs (High Dependency Units) In-patient beds Operation Theatres Top 4-5 medical and surgical specialties( For surgical specialities please provide 2-3 key procedures performed) Number of Beds/ Rooms

4 Operational Parameters Comments (Please highlight significant achievements and reasons that drove it) Total number of beds Overall Occupancy (%) Occupancy %( Critical care) Occupancy %( Non-Critical care) Medical to surgical mix of patients - By number of patients -By Revenue earned Number of outpatients Number of inpatients (patients who were admitted at least for one night) Number of day care patients (if applicable) Average Length of Stay (ALOS) (in days) Hospital acquired Infection rate (%) Turnaround time(tat) for Patient discharge (in minutes) Idle waiting time in OPD services (in minutes) Turnaround time(tat) for Laboratory reports (in minutes) Turnaround time(tat) for Operation Theatre services and utilisation (in minutes) Turnaround time(tat) for Ambulatory services (in minutes) Section 4 Financial Health (if applicable) * Metric ( Rs Lakhs) Comments Gross revenues Operating profitability (%) Section 5 Academic research and training A) Man power in the organization: as on 31 March 2016 (if applicable) Category Total Employees(including Contractual staff) Senior Doctors (Consultants and above) Junior Doctors (Associate consultant, Senior Resident, Resident) Number of Personnel deployed

5 Category Nurses Nursing Aid (GDA) Administrative staff Contract employees(not included above) Number of Personnel deployed Section 5B Academic research and training is only applicable for Customer service improvement and Skills & development B) Description on the trainings undertaken by the organization (All data should pertain to the period April 1, 2015 to Mar 31, 2016) Information required: Total hours of training conducted in the organization : 1 (for all employees including outsource staff) 2 Trainings attended 2.a Doctors (eg.cme) 2.b Nurses (eg.cne) 2.c Technicians 2.d Support staff 3 Total number of hours of CME conducted Total number of hours 4 Total number of hours of total CNE conducted: Average hours/person/year Technical/Skill related Soft skill Technical/Skill related Soft skill Section 6 Accreditations Accreditation Year of Accreditation Number of non-compliances review by the accreditation committees in the last one year JCI NABH ISO Others Section 7 Case Study A) Project / Initiative / Innovation * 1. Summarise the project / initiative/innovation which you are entering for the Awards This should clearly explain the jury members what the case study is about and should summarise remaining part of the application form

6 Innovation is defined as a new solution or an older solution implemented in a new way to achieve the goal a) Explain in brief the problem identified or inspiration for the project, initiative or innovation (max 100 words) b) Describe the project/ initiative/innovation undertaken to solve the problem identified (max 200 words) c) Project/initiative/innovation start date (DDMMYY): Project/initiative/innovation implementation date (DDMMYY): d) What were the cost involved to run the project/initiative/innovation (max 75 words) e) Use of manpower deployed implemented by the organisation to address the above problem (max 100 words) f) Describe the future potential of your project/initiative/innovation in terms of its Replicability across other organisations and locations. Describe briefly (max 75 word)

7 g) Other highlights to showcase how innovatively the initiative / project / product were implemented in your organization (Max 150 words) 2. Describe the 3 unique aspect of your initiative implemented (max 225 words ) B) Impact * 1. Describe the benefits of implementing the above innovation or initiative to various parameters depending on the category selected. Please explain the parameters on the Business, Operations, Patents, Employees, Patients, others etc applicable to the category selected Impact should be measurable and generic statements should be avoided. parameters (max 200 word) Change in percentage / absolute numbers YoY / MoM must be mentioned Parameter Measurable impact

8 2. Describe the impact of the project/ initiative/innovation on the following parameters (max 75 words per parameter) Parameter Pre-launch (up to 1 year prior to launch of the initiative) Post-launch (up to 1 year after launch of the initiative) Patient base number Revenue growth Others (Please specify) Others (Please specify) Others (Please specify) C) Sustainability * 1. Please describe the key developments from your end to ensure the sustainability of the initiative in the long run (max 200 words) Details of any other awards or certification(s) obtained by the organization (Please provide supporting documents) Any other information about the company you wish to tell the jury: (max 100 words)

9 Section 8 Participant Declaration I declare that the information provided in this entry form is correct and accurate to the best of my knowledge. I agree to abide by the rules and regulations of participation. I /We agree, on behalf of my/ our Organization authorise the award management to use the content submitted as part of my/our entry, in whole or in part and use and display such entry, which shall include trade publications, press releases, electronic posting to the Awards website, electronic hyperlinks to the website of the Participant, and any display format selected by the award management during the awards ceremony or at a later point in time, for a period of five years. Participant s name: Signature: Designation: COMPANY STAMP Date: * The Application Form needs to be signed by the authorized signatory from the participant organization (Senior Management)