Primary Care Consultation Profile 2009

7/28/2019 Primary Care Consultation Profile 2009

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Joint Commission InternationalConsulting

Consultation Profile forPrimary Care Centers



JOINT COMMISSION INTERNATIONAL JOINT COMMISSION INTERNATIONAL

Consultation Profile for Ambulatory CareConsultation Profile for Ambulatory Care

PLEASE COMPLETE SECTIONS I, II AND III FOR PROPOSALS. SECTIONS IV AND V SHOULD BE COMPLETED ONCE THE PROPOSAL HAS BEEN SIGNED.

I. Customer Information

1. Organization Name:

2. Address:

[street number] [city/province]

[postal code] [country]

Website:

3. Main Telephone Number:

[country code] [city code] [number]

4. Ownership:

[Owner Name/Company]

[Ownership Type](e.g. private-non governmental, governmental-military)

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5. Ownership Primary Contact:

Name:[Mr./Mrs./Miss/Ms./Dr.]

Title:

E-mail:

Tel:[country code] [city code] [number]

Fax:

[country code] [city code] [number]

6. Staff Information:

Chief Executive Officer: (or equivalent)Name:

[Mr./Mrs./Miss/Ms./Dr.]

E-mail:


Fax:[country code] [city code] [number]

Chief Medical Director: (or equivalent)Name:

[Mr./Mrs./Miss/Ms./Dr.]

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7. Consultation Coordinator: (provide contact information)


E-mail:



Please note the following important information about this profilefor JCI consulting

This profile for consulting from Joint Commission International (JCI), theinternational arm of The Joint Commission, requests information onindividuals that may be considered personal, for example, name, titles, andemail address. We want you to know how we manage that information.

All the information in this profile, including any personal information, isstored on computer servers of The Joint Commission in the United States.

This personal information supports a profile for consultation and theconsulting process which may include, standards and measurementnewsletters, and meeting announcements, for example. When appropriate,profile information is shared with JCI’s consulting partners or with thoseoutside of The Joint Commission for purposes of database management andhosting services. Consent will be obtained for any other use. Personalinformation on the profile can be reviewed and updated at any time and willbe retained as long as needed for consulting purposes, or as required by lawor regulation.

By signing this profile for consultation, consent is granted for the collection,

processing, disclosure and transfer of the personal information in the profileas described above.

II. ORGANIZATIONAL DESCRIPTION:

8. Base upon the standards manual, which level of service doesyour primary Care (PCC) provide?

Basic and essential services: _____

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Additional services:______ Advanced services: ____

9. Does the PCC operate under a license or other regulatoryagreement?

10. LIST WHO LICENSES THE PCC OR GIVES AUTHORITY TO OPERATE:

______________________________________________________

11. HOW MANY SITES/LOCATIONS DOES THE PCC OPERATE? ______12. List the Services and procedures provided by the PCC:

13. DOES THE PCC HAVE ANY HOLDING OR OBSERVATION BEDS?

______________________________________________________

14. Does your organization provide services in the patient’shome:

Yes If you answered “yes”, please complete #15 & 16below.

No If you answered “no”, please skip to question #18 inthe next

section.

15. Average number of patients visited in the home per dayby all staff:

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16. Please indicate the type of care provided in the patient’s

home: Home Health (nursing service)

Personal Care and support

Home Medical Equipment

Home Pharmacy

Hospice Service/Palliative Care in the home

Other

17. Please indicate the procedures performed in apatient’s home:

Ventilator management Wound care

Tube feedings

Parenteral infusions

Urinary catheterization

Care of intravascular devices (porta cath, PIC line)

Other

18. List the agencies the PCC has identified and included intheir scope of services:

Physician led clinics

School health agencies

Long term care

Homeless shelters

Nutrition support centers

Geriatric day-care

Rehabilitation facilities

Other

19. Does the PCC provide the following:

Pharmacy on-site

Medication storage area

Diagnostic imaging services

Radiology services used in the provision of dental services

Medical transport to acute care centers

Laboratory services

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Rehabilitation facilities

Other

20. List any Contracted Services:

21. PCC Locations: List PCC locations, the Number of Visitsand the Type of Service Provided

Name of

PCCLocationsfor Basic/EssentialServices

Numbe

r of AnnualVisits

Type of

Care Given

Floo

r Facility/Site

Anesthesi

a /SedationAdministered

SurgeryCenter

225 Podiatry 1 Building G Yes

BehavioralHealth

175 Mental Health 1 Main Site No

TotalNumber of AnnualVisits

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22. Are there any sites over 1 Kilometer from the mainsite?

____________________________________________________

23. Please provide your usual hours of operation, such as forPCC, and provide information on any daily religiousobservances, staff functions, etc. that will need to be partof or affect the agenda and activities of the team.

Return Completed Consultation Profile by FAX or EMAIL to:Fax: +1 630 268 7405

E-mail: [email protected]

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mailto:[email protected]




COMPLETE THE FOLLOWING WHEN A PROPOSAL IS SIGNED:

IV. SCHEDULING AND TRAVEL: (SECTION MUST BE COMPLETED IN F ULL )

Please indicate three months in which the organizationcould have the consultation scheduled:

Month Year

Please indicate up to a MAXIMUM of five other weeksduring the year to avoid scheduling a consultation, if thepreferred months cannot be accommodated.

FromDD/MM/YY

ToDD/MM/YY

Travel Instructions:*

Air Transportation:

Please indicate the airport(s) nearest to your organizationthat the consultants should fly into:

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Ground Transportation:

Please provide the following instructions to assist theconsultants in making their ground transportationarrangements.

Travel directions from airport to hotel:

Travel directions from hotel to organization:

Recommended method of transport (taxi, car

service):

Assembly point at organization whenconsultants arrive:

Recommended Hotel Accommodations: (internetaccess is required)

Please recommend two to three business hotels near your organization that have internet access. Internet access is

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required for the consultants to complete the consultationreport each evening. If possible, please include theMarriott, Hilton or Intercontinental hotel nearest to your

organization, as these hotels provide preferred rates for the consultants. If your organization has a preferred ratewith business hotels near your organizations, pleaseinclude the specific information and directions for obtaining the preferred rates for consultants.

Hotel Name Address Telephone/Fax(pleaseincludecountry andcity code)

E-mail / WebSite

*For insurance/security purposes the consultant team is

required to make travel reservations through JCI's travel agent.

Please enter any comments or other information you feelmay be pertinent to your consultation.

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(T HIS PAGE / SECTION WILL NEED TO BE PRINTED AND FAXED TO JCI.)

V. FINANCE

Name and title of individual responsible for processinginvoices and payments:


Title:

E-mail:



VI. REPORT FOR CONSULTATION:

The consultation report (consultants’ findings) should be sent to:

Name:

Title:

Signature:

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WIRE TRANSFER FORMPlease complete the following information and fax this Finance section to JCIprior to the consultation. JCI’s fax number is +1-630-268-2992. If you haveany questions about invoices or payments, please [email protected]

Organization:

Name: Title:



Amount of transfer: $ U.S. DollarsDate transfer will occur:Service dates from to . Transfer Description:

The wire transfer, in U.S. dollars, should be sent to JCI’s account at The

Northern Trust Bank, One Oakbrook Terrace, Oakbrook Terrace, Illinois60181, U.S.A.

JCI's account number is: 1054386 JCI’s Swift Code: CNORUS44

JCI’s ABA number is: 071000152



Primary Care Consultation Profile 2009

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