primary care consultation profile 2009
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7/28/2019 Primary Care Consultation Profile 2009
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Joint Commission InternationalConsulting
Consultation Profile forPrimary Care Centers
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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:
Tel:[country code] [city code] [number]
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)
Name:[Mr./Mrs./Miss/Ms./Dr.]
E-mail:
Tel:[country code] [city code] [number]
Fax:[country code] [city code] [number]
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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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:
Name:[Mr./Mrs./Miss/Ms./Dr.]
Title:
E-mail:
Tel:[country code] [city code] [number]
Fax:[country code] [city code] [number]
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:
Tel:[country code] [city code] [number]
Fax:[country code] [city code] [number]
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