Become a CareOne Hospital Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.BrokerName *FirstLastAddressAddress Line 1CityState / Province / RegionLayoutPhone number *WhatsApp Number *Email Address *HospitalName *FirstLastAddressAddress Line 1CityState / Province / RegionLayoutWardEmailContact Number:WebsiteMDName *FirstLastLayoutPhone NumberWhatsApp NumberEmailGeneral InformationLayoutHow old is the hospital (years)? *Less than 2 2-56-1011-20Over 20The Hospital is owned by? *Please Select oneBusinessmanCorporate BodyDistant RelationMD’s ParentMDLayoutHow many registered patients does the hospital have *Less than 20002,000-5,0006,000-10,00011,000-20,000Over 20,000What is the Average Monthly Patient Turnover (in the last 6 months)? *Less than 200200-500551-800801 - 1000Over 1,000Layout How many beds are in the hospital? *Less than 55 - 1011 - 1516 - 20Over 20How many HMOs is the hospital registered with? *Less than 2 2-56-1011-20Over 20What is the average percentage of occupancy (%)? *Less than 20%20%-50%51-70%71% - 90%Over 90%What is the reputation of the hospital? *Very PoorPoorGoodVery goodExcelentLayoutThe Hospital is in what area of the city?* *PoorLower ClassMiddle-ClassHigh BrowPoshHow close is the hospital to the major road in the area?Far from the main roadNear the main roadOff-Off the main roadOff the main roadBang on the main roadLayout (copy)How busy is the Main Road Close to the hospital? *Not BusySomewhat busyAveragely BusyVery BusyExtremely BusyWhat Community Centre is the hospital close to? *NoneChurch/MosqueEstateSchoolMajor MarketLayout (copy) (copy)Is there a dumpsite close to the hospital? *NoYesHow many banks are on the same street as the Hospital?01 - 23 - 56 - 10 Over 10LayoutHow many hospitals are within 10km of the hospital?01 - 23 - 56 - 10 Over 10On a Scale of 1 - 10 how will you rate the location of the hospital?Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10LayoutHow many Staff does the hospital have? *Less than 2 2-56-1011-20Over 20How many months' salary does the hospital owe staff? *Less than 2 2-56-1011-20Over 20How much General Staff training did the hospital conduct in the last 12 months? *Less than 2 2-56-1011-20Over 20Do the hospital has any of these arrangements with staff?NoneSurgery CommissionPerformance BonusProfit SharingStock OptionsWhat's the general attitude of the staff?Very SadSadIndifferentSomewhat HappyVery HappyHow many staff are more than 5 yrs in the hospital? *Less than 2 2-56-1011-20Over 20Does the Hospital have any of this in place?NoneClinical StandardsStandard Operating ProceduresClinical ProtocolsIntegrated Care PathwaysOn a Scale of 1-10 How likely do you think a Staff will refer his/her friend or family to work in the hospital?Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10LayoutThe Hospital is sitting on how many Sq. Meters of Land?Less than 10,00010,001 - 20,00020,001 - 50,00050,001 - 100,000Over 100,000The Hospital has the following alternative source of power. NonePetrol GeneratorDiesel GeneratorInvertersPower PlantCheck all appropriateIs the hospital accredited by the State Licensing Board?NoYesGenerally the facility appears…Run-downUnkeptNeatVery neat and well-keptBeautifulThe Hospital is on how many floors?1234Over 4Does the hospital operate Electronic Medical Records? Not ConsideredOccasionally ConsideredEvaluating Software to implement Implemented but not up and runningFully up and runningIs there a dispute on the facility?NoYesDoes the facility have any external accreditation?NoneSQHN SafeCareCOHSASAJCILayoutHow much monthly revenue does the hospital generate (Nm)? *Less than 2 2-56-1011-20Over 20How much is the Hospital owed by HMOs (Nm)?Less than 2 2-56-1011-20Over 20The Hospital owes pension payments (Nm)Less than 2 2-56-1011-20Over 20he hospital owes suppliers (drugs/lab/Medical Equipment) (Nm)Less than 2 2-56-1011-20Over 20How much monthly expenses does the hospital incur (Nm)? *Less than 2 2-56-1011-20Over 20The Hospital owes tax payments (Nm)Less than 2 2-56-1011-20Over 20The hospital owes rent payments (yrs):Less than 1233Over 4How much cash does the hospital have in the bank right now (Nm)?Less than 2 2-56-1011-20Over 20Submit
