Instructions

Please complete each section of this form - Clicking on the section titles below will take you directly to the relevant tab. In addition you will need to attach your company organisation chart, chargemaster, CQC certificate, indemnity insurance certificates, list of consultants and bank details.

Failure to complete this form with in an agreed timescale will impact the recognition of your facility.Only complete one application for all facilities you are requesting recognition for.

If a box is not relevant to your business please insert N/A - Do not leave any boxes blank.

Contents

1. Overview

Please provide organisational details, including continuity plans and indemnities/liability cover which are in place for your organisation.2. Senior Management Team/Key Contacts

Please provide the names and position of the senior management team and key contacts.

3. Provider Questionnaire

Please answer all questions inserting N/A if not applicable to your organisation.

4. Specialties & Services

Please provide us with a full list of specialties and services that are available, if specialties and services differ at each site, please be clear which services are available at each facility. You are required to provide additional information if you are proposing to provide scanning services (MRI, CT and PET).5. Scanning Services (MRI/CT/PET)

Please complete this section if your proposal includes Scanning Services

6. Consultants

Please provide a complete list of Consultants who have been granted practicing privileges at your facilities, including GMC number and AXA Provider Recognition Number if available.7. Chargemaster

Please provide a full list of services and treatments, covering surgical and diagnostic procedures, giving details of the relevant CCSD coding, CCSD narratives and proposed pricing. ANY service or treatment NOT included in your proposal for recognition will be excluded from our agreement with you.8. Care Quality Commission Registration

Please attach a copy of your CQC registration certificate with your application along with any current action plans.9. Payment Method

All invoicing MUST be submitted electronically via EDI on Healthcode

Your payment method will automatically be defaulted to cheque payment, unless you provide your bank details on signed headed paper.

AXA PPP MEDICAL FACILITY RECOGNITION

1. Overview

COMPANY REGISTERED ADDRESS

Name:

Address:

Company Established:

Main Telephone Number:

Email:

Website Address:

Company Reg Number:

Name of Key Shareholders and their shareholding percentagePlease describe any prospective plans for future development, including:

Growth Market share New service lines Site Developments

FACILTY ADDRESS (if difference from registered address)Name:

Address:

Main Telephone Number:

Email:

Company Reg Number, if differs from registered company above.Website Address:

Date facility opened:

ORGANISATIONAL OVERVIEW

Please attach a copy of your company’s organisational chart to this application.

Number of Employees: Medical Non medical

Department / Business Unit Number of employees % of Total

Do you provide services to NHS patients?If yes what this case mix between Private and NHSIf you provide services to NHS patients how does your organisation differentiate between Private and NHS?Accreditation JAG, UKAS, CHKS, ISO etc.

Certification / Award Certification Number Date Awarded

RISK AND CORPORATE GOVERNANCE

Do you have a Business Continuity /Disaster Recovery Plan in place for all locations?Please confirm that your BCP/DR plans are tested at least annually and confirm when the last successful test was performed?PUBLIC LIABILITY INSURANCE:

What is the maximum cover held:

Policy Number:

Insurer:

PROFESSIONAL INDEMNITY INSURANCE:

What is the maximum cover held:

Policy Number:

Insurer:

EMPLOYERS LIABILITY INSURANCE:

What is the maximum cover held:

Policy Number:

Insurer:

CYBER AND DATA RISK INSURANCE:

What is the maximum cover held:

Policy Number:

Insurer:

2.Senior Management Team/Key Contacts

CEO / Managing Director:

Landline Telephone Number:

Email:

Mobile Telephone Number:

CFO/Finance Director

Landline Telephone Number:

Email:

Mobile Telephone Number:

Registered Manager:

Landline Telephone Number:

Email:

Mobile Telephone Number:

Clinical Lead:

Landline Telephone Number:

Email:

Mobile Telephone Number:

Contracts Manager:

Landline Telephone Number:

Email:

Mobile Telephone Number:

Head of Quality and Governance

Landline Telephone Number:

Email:

Mobile Telephone Number:

Business Development Manager:

Landline Telephone Number:

Email:

Mobile Telephone Number:

3. Provider Questionnaire

Please answer each question, type N/A if not relevant to your facility.

1. Facility

Number of single inpatient beds

Number of inpatient beds in shared rooms

Coronary Care Unit

Critical Care – Level 2

Critical Care – Level 3

Additional Care Units, please give details.

Daycase unit – Number of beds/ bays

Number of Theatres

Number of recovery bays

Do you have an Endoscopy Suite?

Do you provide outpatient surgical procedures?

Do you provide outpatient diagnostics?

Is IV sedation provided?

Are imaging services provided on site?Do you have an on-site pathology lab? If not please specify third party arrangements.

Number of consulting rooms

Number of treatment rooms

Private Patient Unit (NHS only)

Dedicated Theatres (NHS only)

Is there dedicated Parking? If so, how many spaces?Is there disabled Access/Parking? Number of disabled spaces?

Are catering services available?

Is there free WIFI?

2. Regulation/GovernanceAre you registered with the Care Quality Commission, Healthcare Inspectorate Wales, Health Improvement Scotland or The Regulation and Quality Improvement Authority of Northern Ireland? Please provide registration number.

If no, please specify reason for non-registration

Name of Clinical Lead

Date of last inspection

Rating from last inspectionIs there onsite RMO cover? Please provide details of coverage.Are all documented clinical governance policies up to date?

If no, what governance policies are currently being reviewed?

Is there a policy for reporting and management of adverse or near miss incidents?

Is there a whistleblowing policy in place?

Is there a documented complaints process?

How often do you review patient satisfaction?Are action plans created and acted upon as a result of patient feedback?Can you confirm all Consultant/Practitioners personal files are up to date and include but not limited to current appraisal, vaccinations and indemnity insurance?

Is all staff training up to date and documented?Can you confirm that you will inform AXA PPP if any consultant is subject to an investigation by the GMC, Police or any other professional body?Are practice privileges reviewed regularly by the MAC, if so how frequently?How regular is Clinical Governance reporting discussed at the Medical Advisory Committee?

Does the Clinical Governance reporting identify

required skills, knowledge and training requirements?

Is there a dedicated infection control nurse?How frequent are risk assessments carried out at the facility?Are patients sent relevant information regarding their treatment and/ or investigation?Are all patients given post-operative instructions and emergency contact numbers on discharge?

Do all procedures conform to NICE guidance?Confirm your pathology unit is accredited with United Kingdom Accreditation Service (UKAS)? (Please provide certificate number)If no, confirm where pathology testing is carried out and that UKAS accreditation is held by the provider. (Please provide certificate number)

3. Paediatrics

Does the facility provide Paediatric Services?

What age ranges of children are seen as inpatient?

Neonatal

0 to 3

3 to 12

12 to 16Do you offer outpatient services to children under the age of 16?Is a lead paediatric anaesthetist available when children are being operated on?Are all appropriate members of staff trained in PALS?Is there a minimum of one registered children’s nurse on duty on the ward at all times when children are admitted?Is a paediatric early warning tool used post-operatively, to monitor the child’s condition and detect early signs of deterioration and a facility available to provide short-term high dependency care in the event of a child becoming critically unwell?Do you have safeguarding procedures in place and links to the local safeguarding team?

Specify SLA arrangements for emergency transfer?

Is parent accommodation provided?

4. Nursing

How many Nurses are employed?

How many vacancies are currently available?

What specialties are the vacancies?

Is agency or bank staff used?

If yes, how often?Ratio of employed to agency/ bank staff used over the last 3 months.

Do all nurses have an annual appraisal?

5. Data Management and Data Protection

 AXA PPP healthcare companies are committed to ensuring personal information is protected, when entering into an agreement with AXA PPP healthcare you are agreeing to comply with all obligations under the Data Protection Legislation.

We are required by law, in certain circumstances, to discuss information to the law enforcement agencies about suspicions of fraudulent claims and other crime. We will disclose information to third parties including other insurers for the purposes of prevention or investigation of crime including suspicion about fraud.

Is medical record keeping in accordance with guidance from the GMC and relevant professional bodies?

Do records include details of consent?Do you perform background verification and security checks for all new personnel (permanent, contract and temporary)?Do your employment contracts include specific sections to protect your information assets, and include employees and contractors responsible for information security?Have you developed and implemented procedures for secure disposal of sensitive media when no longer required?Do you have physical security measures Not in place covering your organisation’s offices, rooms and facilities?How does your organisation safeguard against cyber security threats?Do you perform at least annually independent security tests, including vulnerability tests and penetration tests, of your networks and applications?What measures do you take to encrypt emails when sending and receiving sensitive information?4. Specialties/Services

Please tell us the specialties and services which are available.

Services where additional documentation is required are denoted by an asterisk (˚)

SPECIALITY SPECIALITY

Cardiology Vascular surgery

Cardiac Hepatic & Billiary Surgery

Dermatology Onsite laboratory (CPA accredited)

Ear, nose & throat Endoscopy unit

General medicine X-ray

Gynaecology Mammography

Maxillo-facial surgery Ultrasound

Neurosurgery CT scan *

Obstetrics CT Coronary Angiography *

Oncology CT Colonography/ CT Arthrography *

Breast Echocardiograph

Colorectal MRI *

Ophthalmology PET *

Oral surgery (F0910/F0950/F1810) Nuclear Medicine

Orthodontics Laser - YAG

Orthopaedics Capsule endoscopy

Paediatrics Ocular photography

Pain management Minor Outpatient Theatre

Podiatry/podiatric surgery Daycare Theatre/Unit

Psychiatry Physiotherapy

Trauma & orthopaedics Other:

Urology Other:

5. Scanning Services (MRI/CT/PET)

Please complete all sections of this document where applicable.

Static Mobile If Mobile, No. of Sessions per week

MRI Half Day: Full Day:

CT Half Day: Full Day:

PET Half Day: Full Day:

Any other scan types offered?

Do you provide these services, if not please advise who does:

Who invoices for these services:

Details of equipment type/size of magnet:

Please supply the following contact names:

TITLE NAME

Senior Radiographer

Senior Radiologist

Registering AuthorityOther (Please Specify)

Recognition of MRI Facilities for Benefit Purposes

In the interest of patient safety, the following criteria must apply, irrespective of whether the facility provides a static or mobile service. Please acknowledge the following by adding “Yes” or “No”. If “No” please provide commentary in the boxes provided.

 Y/N Commentary1. The direction and management of the MRI facility will be the responsibility of the health authority, hospital or mobile clinical institution responsible for the patients undergoing examination

2. There will be a guarantee that the facility meets the statutory requirements of the UK Health and Safety at Work Act 1974, including reference to the latest version of any amendments.3. Magnetic resonance (MRI) equipment will be contained within a designated controlled area.

4. There must be strict control of all personnel having access to the equipment and its immediate environment. The employing body will maintain a list of Authorised Personnel. For optimum safety:

a) the responsibilities of management and staff must be formally documented and understood by all personnel;

b) there must be evidence that staff are appropriately trained in the use of MRI devices and fully understand the safety aspects and possible hazards of the magnetic field;

c) an MRI adviser who has the appropriate training, knowledge and experience of MRI equipment, its uses and associated requirements, must be appointed to offer consultative advice.

5. An appropriately trained and experienced person (termed a "responsible person") must be in charge of the department, responsible for ensuring that comprehensive written safety procedures, work instructions and operating instructions are available to all staff involved with MRI devices, following full consultation with the magnetic resonance advisor(s).

6. A designated consultant radiologist must be responsible for agreeing the clinical protocols of the unit, which should be documented for each common clinical situation with particular reference to the Royal College of Radiologists' guidance, "Making the Best Use of a Department of Clinical Radiology".7. A consultant radiologist must be available on site when any procedure is undertaken.

8. A full list of procedures/treatments undertaken, plus those specialist users with admitting privileges must be provided. A mechanism should also be in place for peer review of new techniques and, where necessary, assessment of individual practice.9. All MRI scans must be reported on by a consultant radiologist within a maximum 24 hour period. Any anticipated irregular findings would require more timely review in order to allow for immediate intervention as appropriate.

10. Questionnaires should be completed by each patient prior to MRI screening in order to identify and warn of any potential hazards.11. Where patients require sedation or general anaesthetic, an appropriately trained and qualified anaesthetist must attend the patient at all times. A fully staffed recovery unit should also be available, situated close to the MRI facility

complete with appropriate monitoring equipment and full emergency backup services.12. Appropriate trained staff must be available for the care of the child throughout their stay in the MRI facility and be skilled in implementing emergency procedures in the event of patient cardiac arrest, collapse etc.

13. A formal resuscitation training programme must be in place for all members of the staff who will be fully conversant with safe resuscitation procedures in relation to MRI devices. Evidence of basic life support certification will be required relevant to both adult and paediatric as appropriate.14. Records of all MRI scans must be kept for a minimum of 10 years and should include, at least, the following:-

a) Equipment reference including update status and static magnetic field intensity;b) Date of scan;

c) Patient’s name or reference, sex and age;

d) Scan data;

e) Region of the body with type of coil used;f) Values of pulse and gradient data;

g) Number, size and orientation of slices scanned;h) Details of contrast media used.

15. A comprehensive manufacturer agreement should be in place to provide planned and emergency maintenance.16. Evidence of an ongoing quality assurance programme will be required.

17. Adverse incident reporting will be required on a quarterly basis with evidence of evaluation and changes in practice as necessary.18. Agreement over charges and for direct settlement of composite bills will be required (composite bills must include the cost of staff and all consumables (including drugs, contrast and sedation), equipment and facilities used and the specialist’s reporting fee).Recognition of CT Facilities for Benefit Purposes

In the interest of patient safety, the following criteria must apply, irrespective of whether the facility provides a static or mobile service. Please acknowledge the following by adding “Yes” or “No”. If “No” please provide commentary in the boxes provided.

 Y/N Comments

1. Registered with the local Health Authority under provisions of the Registered Homes Act 1984, if applicable (copy certificate to be provided).

2. All statutory and professional requirements met, including:-

a) The Ionising Radiation Regulation 1985, 1988 and 1999;

b) Health and Safety legislation, including COSHH regulations;c) The Approved Code of Practice against Ionising Radiation;d) The National Radiological Protection Board Guidance Notes.3. Written local rules relating to ionising radiation regulations.

4. Appointed Radiation Protection Advisor (name and address to be supplied).5. A named consultant radiologist takes clinical responsibility for the unit and is responsible for written clinical policies.6. AXA is provided with a full list of procedures available and a list of consultant users.

7. Charges are agreed with AXA and include all equipment, consumables and services including consultant reporting fees which are the responsibility of the facility.

8. All CT scans must be reported on by a consultant radiologist within a maximum 24 hour period. Any irregular findings would require more timely review in order to allow for immediate intervention as appropriate.9. Appropriate trained staff must be available for the care of the child throughout their stay in the CT facility and be skilled in implementing emergency procedures in the event of patient cardiac arrest, collapse etc.

6. Declaration

I confirm that the information provided in this form is correct to the best of my knowledge and I am agreement [PROVIDER NAME] will not provide any service to AXA PPP Members unless agreed in writing beforehand.

For and behalf of [PROVIDER NAME]

---------------------------------------- ------------------------------------------Signature Full Name

--------------------------------------- -------------------------------------------Position in Company Date

Additional Required Information

6. Consultants

Please provide a complete list of Consultants who have been granted practicing privileges at your facilities with the following details:

Name AXA PPP Provider Number GMC Number Main Specialty Sub Specialty

7. Chargemaster

Please complete the attached chargemaster template detailing prices for all services and treatments and including CCSD codes where appropriate. Chargemasters MUST include all ancillary charges.

8. Care Quality Commission Registration

Please attach a copy of your CQC registration certificate with your application

9. Payment Method

Please provide your bank details and healthcode number on headed paper accompanied by a signature. All invoicing must be submitted electronically via EDI on healthcode.

WWW.HEALTHCODE.CO.UK

Customer Services 01784 263150

registrations@healthcode.co.uk