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NHSF Added Service Application Form
General Facility Information
Facility Name:
*
Owner(s):
*
Address:
*
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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
Select files
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
Select files
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
Select files
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
Select files
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
Select files
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
Select files
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
Select files
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
Select files
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
Select files
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.
Comments
This field is for validation purposes and should be left unchanged.
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