SurgiCenter Professional Liability Application

CONTACT INFO
Applicant Name
Practice Name
Email
Street
Street
City, State, Zip
Phone
Fax
Key Contact's Name
Web site (if applicable)
Federal Tax ID
Years in Business
Hours of Operation
Management Co.

Ownership of Center
	A.	B.	C.
	Individual Partnership Corporation Joint Venture	Profit Non-Profit Charitable Government	Licensed by the State Accredited by AAAHC Medicare Approved Accredited by JCAHO Other

Current Coverage

Professional Liability (Claims Made Only) Effective Date:
$ Limit: per claim. $ aggregate.
Retroactive Date:
Deductible: $10,000 $25,000 $50,000 Other

General Liability Effective Date:
$ Limit: per claim. $ aggregate.
Retroactive Date:
Occurrence, or Claims-Made
Deductible:
$10,000 $25,000 $50,000 $100,000 Other

Exposure Info

Please document type by number of surgical procedures performed at your facility below:

Procedure Type (Surgical Specialty)	Current Year	Projected - Next 12 months
Bariatrics
Cardiac
Colon and Rectal
Endoscopy/Colonoscopy
Dentist - Oral Surgery
Gastroenterology
General Surgery
Gynecology
Hand Surgery
Head and Neck Surgery
Lasik
Neurology
Ophthalmology
Orthopedic
ENT (Ear/Nose/Throat)
Pain
Plastic (Cosmetic or Reconstructive)
Podiatrist
Urology
Thoracic
Vascular
Other:

Facility class definitions by type of anesthesia (please check all that apply):

Class A	All surgical procedures are performed in the facility under local or topical anesthesia.
Class B	Surgical procedures are performed in the facility under local or topical anesthesia and/or intravenous or parenteral sedation, regional anesthesia, analgesia, or dissociative drugs (excluding Propofol) without the use of endotracheal or laryngeal mask incubation or inhalation general anesthesia (including nitrous oxide).
Class C	Surgical procedures are performed in the facility under local or topical anesthesia and/or intravenous or parenteral sedation, regional anesthesia, analgesia, or dissociative drugs, including Propofol, spinal or epidural anesthesia, endotracheal or laryngeal mask incubation or inhalation general anesthesia (including nitrous oxide), administered by an anesthesiologist or certified anesthetist.

Health Care Professionals:
Please indicate total number of employees in each category below:

Position	Full-Time Employees	Contractors	Volunteers
Physicians/Surgeons
Aides
Dentists
CRNA's
Nurse Practitioners
Occupational Therapists
Pharmacists
Physical/Speech Therapists
Physician/Surgeon Assistants
Podiatrists
RN's/LPN's/LVN's
Technicians
Other:

Do you confirm that all practitioners working at the center have current hospital privileges?

Yes No

If no please provide a list of those physicians who do not have privileges and explanation in box below:

Do you treat athletes?

Yes No

Has any insurance company ever canceled, refused to renew, restricted coverage through endorsements to the policy or only offered coverage to you with a deductible or in a higher rating plan?

Yes No

Services / Facilities

Please indicate if the applicant presently provides or operates, or plans to provide or operate any of the following:

Abortion Clinic	General Surgery	Out-Patient Surgicenters
Ambulance Services	Geriatrics	Pain Management
Birthing Suites	HMO	Pathology
Blood Bank	Home Health Care	Pediatrics
Burn Units	Hospice	Rehabilitation
Cardiac Catheterization Center	Intensive Care Unit	Research / Experimental Surgery
Chemical Dependency	Long-Term Care	Skilled Nursing
Coronary Care Unit	Neonatal ICU	Transplants
Day Care	Nursery	Transportation (non ambulance)
Dental Services	OB/GYN	Trauma Centers
Dialysis	Oncology
Emergency Room	Open Heart Surgery
Fitness Center	Organ Transplants
General Medicine

List any additional services in the box below:

Risk Management/Quality
1.	Risk Management/Performance Improvement
	a.	Who coordinates your risk management program?
		Name:	Title:
		Address:	City/State/Zip:
		E-mail:	Telephone w/ Area Code:
2	Credentialing
	a.	Is history of previous employment verified for all employees or physicians ?		Yes No
	b.	Are references checked for all employees or physicians?		Yes No
	c.	Has the license of any employed / contracted physician or surgeon ever been restricted or suspended?		Yes No
		If yes, please explain:
	d.	What are the minimum limits of malpractice insurance required for providers ?
		per occurrence / aggregate
	e.	Are providers allowed to post bonds or letters of credit instead of insurance?		Yes No
		If so, how is this verified:
3.	Hold Harmless and Indemnification Agreements
	a.	Has the facility agreed to hold harmless or indemnify others under contract?		Yes No
		If yes, please e-mail a copy to Steve at MedRisk, LLC.
	b.	Does the facility rent or lease any equipment from others?		Yes No
		If a) or b) is yes, please explain:

Environment, Policy, and Procedures
For all questions answered "no" below, please provide a written explanation.
1.	Is each operating room of a size adequate for the presence of all equipment and personnel necessary for the performance of the surgical procedures, and complies with all local, state, and federal requirements?
	Yes No Explain (if no):
2.	Is a weekly spore test performed and the results filed for each autoclave?
	Yes No Explain (if no):
3.	Each sterilized pack is marked with the date of sterilization and, when applicable, with the expiration date.
	Yes No Explain (if no):
4.	Does the facility maintain a standard defibrillator or AED which is checked at least weekly?
	Yes No Explain (if no):
5.	Are Nasopharyngeal airways and laryngeal mask airways always available?
	Yes No Explain (if no):
6.	Are all medications included in the ACLS Algorithm available on the emergency cart and a copy of the ACLS and Malignant Hypothermia Algorithms maintained on the cart?
	Yes No Explain (if no):
7.	Are all narcotics and controlled substances secured with a double lock?
	Yes No Explain (if no):
8.	Is there a dated sequential narcotic inventory and control record which includes the use of narcotics on individual patients?
	Yes No Explain (if no):
9.	Is the narcotic inventory checked and verified at least daily by two qualified individuals?
	Yes No Explain (if no):
10.	Are all medications inventoried (outdated purged) and recorded in the patient's record when administered?
	Yes No Explain (if no):
11.	Are the following stored in the facility at all times?
	Amiodarone?	Yes No
	Preservative free H2O diluentents for Dantrolene?	Yes No
	NaHCo3?	Yes No
	Dantrolene?	Yes No
	Intravenous corticosteroids?	Yes No
	Anti-hypertensives?	Yes No
	If "No" was checked on any of the above, please explain:
12.	Are all intravenous and subcutaneous fluids recorded as to type and volume?
	Yes No Explain (if no):
13.	Are intravenous fluids available in the facility and does the facility have a means for obtaining or administrating blood or blood products?
	Yes No Explain (if no):
14.	Is there a written protocol for the administration of blood products that includes typing, cross matching, double checks and verifications?
	Yes No Explain (if no):

General Safety
1.	Have all the National Patient Safety Goals been fully implemented?	Yes No
2.	Is there a written policy in place for?
	Patient identification	Yes No
	Surgical site verification	Yes No
	Patient positioning	Yes No
	Laser / electrical safety	Yes No
	Continuous physiological monitoring	Yes No
	Documentation of all intra-operative orders	Yes No
	Disposition of all pathology and other specimens	Yes No
	Verification of sponge, needle, and instrument counts?	Yes No
	Documentation of patient condition, mode of transport for hospital transfers	Yes No
	Completion and signing of operative reports which includes a written, immediate post surgical report	Yes No
3.	Is there a written emergency transport policy and agreement with a local hospital? How many miles to nearest hospital:	Yes No
4.	Is a medical history and physical exam recorded on all patients for major surgery and thosde minor surgery patients whose age, medical condition, and complexity of procedure merit it?	Yes No
5.	Are medical records kept secure and confidential in a manner consistent with HIPAA?	Yes No
6.	Are all Operating Room and Recovery Room employees Basic Life Support Certified at a minimum? (ACLS is preferred.)	Yes No
7.	Is there a written Performance Improvement Plan?	Yes No
8.	Is there a written Risk Management Plan?	Yes No
9.	Is there a formal Peer Review Process that includes both review of random cases as well as unanticipated events (such as complications and infection) for both surgery and anesthesia?	Yes No
10.	Is credentialing which includes primary source verification performed on all providers?	Yes No
11.	Are specific privileges awarded to individual physicians made aware and readily available for all staff?	Yes No
12.	Is a Patient's Bill of Rights posted in a prominent place and distributed to patients?	Yes No

Anesthesia Care
1.	Is there a written process in place for patient selection (ASA criteria or other)?	Yes No
2.	Are all anesthetics delivered by either a qualified physician or CRNA (under physician supervision if required by the state or the facility?	Yes No
2.	Intraveneous sedation other than Propofol may be administered by a RN if supervised by an appropriately qualified and privileged physician.
3.	Is a physician responsible for determining the medical status of the patient immediately before surgery?	Yes No
4.	Has a physician verified that the patient - or responsible adult - engaged in a comprehensive informed consent process and has a signed surgical consent?	Yes No
5.	Are all patients assessed by cardiac and 02 monitoring during surgery and recovery from anesthesia?	Yes No
6.	Is a post anesthesia care area used to recover all patients after anesthesia administration?	Yes No
7.	Is a post anethesia care record maintained?	Yes No
8.	Is a physician, CRNA, or RN with Advanced Cardiac Life Support (ACLS) or certification of who is otherwise qualified in resuscitation immediately available until all patients have met the criteria for discharge from the facility?	Yes No
9.	Do all recovering patients remain under direct observation and supervision until discharge from the recovery room?	Yes No
10.	Are written post operative instructions provided to all patients?	Yes No
11.	Are patients required to meet established written and recorded criteria for stability before discharge?	Yes No
12.	Are patients who receive anesthesia, other than local, prohibited from driving themselves home?	Yes No
13.	Are facilities with 23 hour or overnight stays in compliance with all regulations?	Yes No

Commercial General Liability Exposure

Add information to the comment box below this table, if needed:

Location	Area	Age	Construction Type	# of Floors	Fire Protection
Patient Care Building One					State City
Patient Care Building Two					State City
Other Buildings					State City

Add more detail into comment box below, as needed:

Employee Benefits Liability Exposures

Number of Employees:

Employee Benefits are self administered

Yes No

Other Expenses

Are there elevators or escalators on any premises owned, leased or occupied by the insured?

Yes No

If so, how many:

List the number and type of owned or leased vehicles:

Do you sell or lease any medical equipment or products to patients of others in connection with your operation?

Yes No

If so, please explain:

Has the applicant sold, acquired, or discontinued any operations in the past ten (10) years ?

Yes No

If so, please explain:

Is the applicant considering any changes in operations or products over the next 12 months?

Yes No

If so, please explain:

Claims History
1.	Have any claims ever been made against you?	Yes No
	Please provide currently valued carrier loss runs:
2.	Are you aware of any incident, circumstance or loss which has occurred after the proposed retroactive date, which is likely to result in a claim	Yes No
	If yes, please provide details:
	Have they been reported to your current or previous carrier(s)?	Yes No

For your own records, you may choose to print this file.

Thank you very much for taking the time to contact us.

SurgiCenter Professional Liability Application

CONTACT INFO

Ownership of Center

A.

B.

C.

Current Coverage

Exposure Info

Services / Facilities

Environment, Policy, and Procedures

General Safety

Anesthesia Care

Commercial General Liability Exposure

Claims History