Telemedicine Project Questionnaire
Hospital or Clinic Name:
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Facility City and Country:
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Name & Contact of Person Filling out Questionnaire:
*
Phone
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Email
*
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HOSPITAL PROFILE
Does the lead physician speak English?
Yes
No
Comments (please explain “no” answers)
Is this hospital private or public (government funded)?
Private
Public (Government Funded)
How many beds are there in the facility?
What wards does the facility have?
How many doctors are on staff?
How many nurses are on staff?
How many other healthcare specialists are on staff?
About how many patients are served each week?
Is the hospital a teaching hospital?
Yes
No
If “yes”, is the hospital associated with a medical school? Which one?
Would you like to explore having this project becoming the basis for a regional hub for telemedicine with a panel of specialists of its own?
Yes
No
Maybe Later
Comments (please explain “no” answers)
Is there any form of electronic medical records?
Yes
No
If “yes”, what is the format?
Are patient records electronic?
Yes
No
Comments (please explain “no” answers)
Are medical supplies accounted for electronically?
Yes
No
Comments (please explain “no” answers)
Who on staff at the hospital will lead the telemedicine project? Name the leader and two other people who will support adoption of telemedicine at the hospital. The leader must be a doctor.
Doctor's Name
Given Name / First Name
Family Name / Last Name
Mobile:
Please enter a valid phone number.
Email
example@example.com
Supporter's Name
Given Name / First Name
Family Name / Last Name
Mobile:
Please enter a valid phone number.
Email
example@example.com
Supporter's Name
Given Name / First Name
Family Name / Last Name
Mobile:
Please enter a valid phone number.
Email
example@example.com
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TECHNICAL ASSESSMENT
What is the number of computers in the hospital?
Are computers used in clinical work?
Yes
No
Comments (please explain “no” answers)
Is there a wired network in place?
Yes
No
Comments (please explain “no” answers)
Is there a WiFi network in place?
Yes
No
Comments (please explain “no” answers)
Is there someone on the hospital staff who performs technical support for the network(s)?
Yes
No
If “yes” please provide name, email and phone number for that person below:
Name
Given Name / First Name
Family Name / Last Name
Mobile
Please enter a valid phone number.
Email
example@example.com
Are electrical outages a problem?
Yes
No
If “yes”, how many took place last week?
What was the usual duration of the outages?
How about last month?
Does the hospital have a generator or solar power for when the electrical grid is down?
Yes
No
Comments (please explain “no” answers)
Do you have an Internet connection?
Yes
No
If “yes”, what type of connection?
Test the speed of the connection using a computer on the hospital network. Go to http://speedof.me and click on Begin Test.
What is download speed?
Upload?
Are internet connection outages a problem?
Yes
No
If “yes” how many took place last week?
What was the usual duration?
How about last month?
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PRELIMINARY BASELINE ASSESSMENT
How many patients per 1,000 have experienced adverse events or complications during their visit/stay at your facility?
Comments (please provide examples/explanations)
How many patients admitted in the past month have died?
Comments (please provide examples/explanations)
How many patients in the past month have been referred elsewhere for higher levels of care?
Comments (please provide examples/explanations)
How many patients have experienced readmissions or transfers to higher levels of care within the last month?
Comments (please provide examples/explanations)
How many reliable external referral sources exist within your network?
Comments (please provide examples/explanations)
How many patients in the past month were unable to seek care from a referral source based on limited resources?
Comments (please provide examples/explanations)
What is the average duration of time physicians are employed by your facility?
Comments (please provide examples/explanations)
What would you estimate the average job satisfaction of healthcare professionals at your facility is on a scale of 1-10?
1
2
3
4
5
6
7
8
9
10
What would you estimate the average job satisfaction of healthcare professionals at your facility is on a scale of 1-10?
Comments (please provide examples/explanations)
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ROTARY CLUB SUPPORT
The goal in Rotary clubs providing equipment is to enable telemedicine to work well and as soon as possible. Key success factors are: 1. An Internet connection 2. Electricity (Generator or solar array may need to be part of the project) 3. An ICU or critical care ward 4. A doctor who wants to work with us and who speaks English 5. A Rotary Club that wants to help the hospital and sees telemedicine as a good project
Name the Rotary club that will support the project
Club Name
Club Location
Name the Rotarians who will lead the host club team to support the telemedicine project and two other members who will support the project. (Note: One of the team members needs to be the President Elect)
Name of the lead
Given Name / First Name
Family Name / Last Name
Mobile
Please enter a valid phone number.
Email
example@example.com
Supporter's Name
Given Name / First Name
Family Name / Last Name
Mobile
Please enter a valid phone number.
Email
example@example.com
Supporter's Name
Given Name / First Name
Family Name / Last Name
Mobile
Please enter a valid phone number.
Email
example@example.com
What hospital or other funds are available for this project?
Source:
Amount:
Submit
Should be Empty: