Category: Preventive Care

Application form

This Award recognises initiatives for promoting and creating awareness about importance of preventive healthcare. Participant should be able to demonstrate through measurable parameters how the initiatives have increased queries / diagnosis conducted for patients for preventive healthcare.

Eligibility Criteria:

  • Any organization participating in the Awards must have at least 2 years of registered presence and operations in India as March 31, 2015
  • The Initiative should be completely executed in the Indian operations of the participant
  • The Awards shall be given to the initiatives in the healthcare sector for the period January 1, 2014 to March 31, 2015
  • Participating organizations must be engaged primarily in providing health care services.
  • Nursing homes, dispensaries, dental 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 Application form

  • Please use permanent ink while completing the form.
  • Forms should be filled in English and Block Letters only.
  • All questions must be answered. Incomplete forms will not be considered.
  • A participating organisation can send entries in more than one award category or apply multiple times in the same category provided it is for a separate innovation project / initiative. A separate form should be used for each application entry. One form cannot be used for multiple projects / initiatives.
  • Please maintain one copy of the completed form with you for your records

If you have any questions, or require any clarifications, please contact Mr Anirudh Sen 011- 23487445; Mr Syed Quasim Ali at 011- 23487220

List of Documents

Mandatory document(These documents are mandatory to provide. Unavailability of these documents can result in disqualification of the participant)

  • Signed & stamped Declaration by the Authorised person of the organisation
  • Copy of certification mentioned in the form

Additional documents(These documents are not mandatory; however, Participantscan 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, audio video, presentations, booklets, references
  • Any other information you would like to highlight

Section 1 – Participant information

 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: ______
 Multispecialty hospital (Hospital which provides 5 basic specialities and having more than 50 beds)
If yes, Total beds ______, Specialities & Revenue contribution ______
 Small healthcare organization - Private(Hospital with less than 50 beds)
 Public (Hospital with more than 50beds, District hospital/ Sub-district hospital-Category 2)
 Small healthcare organization-Public (Hospital with less than 50beds,Sub-district hospital-Category1)
 Radiology Laboratory
 Pathology Laboratory
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 centers / branches / offices
Number of cities with presence
Contact person / Name:
Email:
Contact:
Address of registered office in India
Year of incorporation
Revenue (Rs. in crores) / Less than 25 / 26 - 100 / 101 -250 / More than 250

Section 2 – Operational metrics

Top level parameters / Number of Beds/ Rooms
Total (Census beds)
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)
Operational Parameters / 2012 – 13 / 2013- 14 / 2014- 15 / 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 (%)

Section 3 – Financial health

Metric ( Rs Lakhs) / 2012 – 13 / 2013- 14 / 2014- 15 / Comments
Gross revenues
Operating profitability (%)

Section 4 – Academic research and training

A) Man power in the organization: as on 31 March 2015

Category / Number of Personnel deployed
Total Employees(including Contractual staff)
Senior Doctors (Consultants and above)
Junior Doctors (Associate consultant, Senior Resident, Resident)
Nurses
Nursing Aid (GDA)
Administrative staff
Contract employees(not included above)

B) Description on the trainings undertaken by the organization(All data should pertain to the period Jan 1, 2014 to Mar 31, 2015)

Information required:
1 / Total hours of training conducted in the organization pertaining to Preventive care :
(for all employees including outsource staff)
2 / Trainings attended / Total number of hours / Average hours/person/year
Technical/Skill related / Soft skill / Technical/Skill related / Soft skill
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
4 / Total number of hours of total CNE conducted:

Section5 – Case study

Please enter factual and specific information for the jury to evaluate. You could attach additional sheets if required. Please provide up to 3 supporting documents wherever applicable, to support your entry details
The project / initiative should focus on improving “Preventive care of the patients” in terms of building a safer environment, focusing its efforts to propagate the concept of wellbeing through preventive health checks in the hospitals etc.
INNOVATON
  1. Describe the problems which you faced and the risks which you anticipated in terms of d to the initiation of the project / initiative(Highlight the issues whichled the hospital / clinic to develop this initiative) ( Max 500 words )

  1. Describe the steps implemented by you to address the above problem.
Highlight the following:
  1. Objectives of the initiative / project( Max 50 words )
  2. Success measures of the initiative / project( Max 50 words )
  3. Time to implement the initiative / project( Max 50 words )
  4. Details of the initiative / project( Max 150 words )

  1. Describe unique aspects of the initiative / project. Highlight how innovatively the project was implemented in your premises to mitigate the risks involved ( Max 300 words )

IMPACT
  1. Describe measurable metrics to demonstrate the success of your initiative / project (building skills in improving patient safety, interventions to improve reliability and care, creating the conditions for the delivery of safer care etc.) ( Max 500 words )

SUSTAINABILITY
  1. What are your plans from your end to ensure sustainability of the initiative in long run?(Max 500 words )

CERTIFICATION / AWARD FOR THE INITIATIVE
6. Describe any recognition/awards/certificates received by the company for its initiatives
Date / Recognition by / Details of the awards/certificate received
Section 7 – 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: ______
Date: ______
* The Application Form needs to be signed by the authorized signatory from the participant organization (Senior Management)