NHSF Added Service Application Form - College of Physicians & Surgeons of Alberta

General Facility Information

Facility Name:*

Owner(s):*

Address:*

Street Address City Province Postal code

Phone:*

Fax:

Facility email:*

Enter Email Confirm Email

What are the routine business hours/days of operation for this facility?

Personnel

Medical Director:

Name	CPSA Registration #	Qualifications	Address for correspondence	Phone	Email

Physicians with privileges:

Application(s) submitted to CPSA
Application(s) in progress

IMPORTANT: To complete this application, you must submit an "Application for Privileges in an Non-Hospital Surgical Facility” for each physician performing procedures in this facility.

Facility Supervisor/Manager:

Name	Qualifications	Phone	Email

Assessment contact:

Name	Phone	Address (if different from facility)	Email

Financial contact:

Name	Phone	Address (if different from facility)	Email

List the number of full time equivalents (where applicable):

Operating room	Recovery room	Management	Reprocessing/sterilizing Tech*

IMPORTANT: Please breakdown to identify those with ACLS, PALS and HCP CRP

Attach copies of HCP CPR, ACLS and/or PALS certificates for all nursing staff where appropriate:
All ACLS courses must include a theory and hands-on training component.

Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.

Drop files here or

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

Attach copies of practice permit/training certificate for reprocessing/sterilizing Tech, if applicable:
Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.

Drop files here or

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

Added procedures being requested

Type of Anesthesia:
General Anesthesia - adult
General Anesthesia - pediatric (<8 years)
Sedation - adult
Sedation - pediatric (<8 years)
Major Regional Block - adult
Major Regional Block - pediatric (<8 years)
Retrobulbar Block - adult
Retrobulbar Block - pediatric (<8 years)
Other
Note: Anesthesiologists with privileges in a Regional Health Authority need only apply once to CPSA for approval to provide services in NHSFs in Alberta. If this is not an initial application, Medical Directors must confirm with CPSA that the anesthesiologist is approved before commencing work in the facility.

Please specify other:

Surgical procedures:
Dentistry - adult
Dentistry - pediatric (<8 years)
Dermatology - adult
Dermatology - pediatric (<8 years)
General Surgery - adult
General Surgery - pediatric (<8 years)
Gynecology - adult
Gynecology - pediatric (<8 years)
Ophthalmology - adult
Ophthalmology - pediatric (<8 years)
Oral & Maxillofacial Surgery - adult
Oral & Maxillofacial Surgery - pediatric (<8 years)
Orthopedic Surgery - adult
Orthopedic Surgery - pediatric (<8 years)
Otolaryngology - adult
Otolaryngology - pediatric (<8 years)
Plastic Surgery - adult
Plastic Surgery - pediatric (<8 years)
Podiatry - adult
Podiatry - pediatric (<8 years)
Urology - adult
Urology - pediatric (<8 years)
Other

Please list 'other' procedures you are interested in adding based on the NHSF Approved Procedures list:

Additional documents you must submit

Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.

Letter from Medical Director indicating what the percentage increase will be to current patient volume and that the NHSF is adequate and safe to include these services:*
Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

Application(s) for physician privileges for the added procedure(s):*

Drop files here or

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB, Max. files: 5.

Organization structure (e.g. Organization chart)*
Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

Letter from the Safety Code Officer verifying compliance of the non-flammable medical gas piping system (if applicable):*
Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

Report of airflow and quality if added services required renovations to the facility:*
Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

Copies of HCP CPR/ACLS/PALS certificates of all nursing staff and physician staff (if applicable):*

Drop files here or

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

Practice permits for all perioperative patient care non-physician staff (i.e. nurses):*

Drop files here or

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

For each piece provide: 1. Manufacturer 2. Model name, and 3. Serial Number

Training certificate of reprocessing/sterilizing tech (if applicable):*

Drop files here or

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

Training records/certificate s of all participating staff specific to their new responsibilities of the added services specific to the NHSF environment (i.e. perioperative personnel, reprocessing/sterilizing staff, janitorial, etc.):*

Drop files here or

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

Evidence of medical emergency preparedness via documentation of added service mock drill(s) (participants must include the added service physicians and applicable facility staff) and signed by the Medical Director:*

Drop files here or

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

All facility Policies and Procedures that were revised or developed to reflect the added procedures:*

Drop files here or

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 30 MB.

At a minimum revision/development required for:

PATIENT CARE
Pre-Operative Evaluation

Intra-Operative Management: Anesthesia

Intra-Operative Management: Surgical

Recovery Room Management

Discharging the Patient

INFECTION PREVENTION AND CONTROL
Occupational Health/Immunization

General Infection Prevention Measures

Additional Precautions

Patient Care Practices

Reprocessing (Cleaning, Disinfection, and Sterilization)

Janitorial and Waste Management

FACILITY

General/Physical Standards

Administration Standards

Operating Room Standards

Recovery Room Standards

EQUIPMENT/SUPPLIES
Added Service Equipment Operational

MANUAL/SPECIFICATIONS
Medical Device Training and Use

OR Pick Lists, Sterile Set Up

OR IPAC Turn Over

ANESTHETIC AND RESUSCITATION EQUIPMENT

Anesthetic Gas Equipment

Medications

Blood Product Supplementation (if applicable)

Cells and Tissues Pathology Management (if applicable)

DOCUMENTATION/RECORDS

Personnel Records

Medical Records

Incident Reports

Reportable Incidents

Storage and Retention

Report to the College of Physicians & Surgeons of Alberta

Research/Device of Clinical Trial authorization (if applicable)

SAFETY STANDARDS

General Facility and Patient Safety

Medical emergencies of the procedure and patient demographic

Medical Compressed Gases

QUALITY ASSURANCE AND IMPROVEMENT

Structure

Process

Outcome

Equipment (applicable to new procedures)

Onsite Equipment & Maintenance – please have the calibration records or maintenance records, as applicable, available for the assessment team on the day of the assessment.

Onsite Equipment & Maintenance:
Type of Equipment (e.g. medical gas equipment, ECG, monitors) Year of Manufacture Serial No. Date Acquired (mm/dd/yyyy) Daily Inspection Documented Regular Maintenance performed by qualified personnel (Indicate name of staff, contractor or N/A)

* Click the + to add additional equipment.

Please have the calibration records or maintenance records, as applicable, available for the assessment team on the day of the assessment.

Signature

Checking this box will act as your signature:*
I have reviewed the information in this form and confirm it is accurate.

Name of Facility Medical Director (or designate):*

Email*
This is the email address we will send a submission confirmation notification to.
Enter Email Confirm Email

Date (should be typed in the format mm/dd/yyyy, as in 03/15/2023)*
MM slash DD slash YYYY

This application must be completed (with attached documents) before we can schedule an assessment date.

Name
This field is for validation purposes and should be left unchanged.

Type of Equipment (e.g. medical gas equipment, ECG, monitors)	Year of Manufacture	Serial No.	Date Acquired (mm/dd/yyyy)	Daily Inspection Documented	Regular Maintenance performed by qualified personnel (Indicate name of staff, contractor or N/A)