General Surgery Center of Excellence “Accreditation” Application Step 1 of 4 25% Date* CONTACT INFORMATIONHospital / Institute Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Hospital PhoneWebsite CEOPhoneExt.COOPhoneExt.Contact Representative (person completing application)PhoneEmail FaxOtherPlease Describe Academic AffiliationsMedical SchoolHow many medical students?Do you have a residency?YesNoIf so, which specialties?ListSpecialtyNumber of Residents Is your Hospital? (Choose all that apply) Community Based (Corporate Chain) Community Base (Locally Owned) Private Academic County City University / State Owned Academic For profit Non-profit If Other, please explain Hospital-Based General Surgeries:**Procedure (CPT-Codes): Completed in 2017Cholecystectomy - All Codes TotalLaparoscopicRobot Appendectomy - All Codes TotalLaparoscopicRobot Small Bowel Resection - All Codes TotalLaparoscopicRobot Colon - All Codes TotalLaparoscopicRobot Nissen Fundoplication - All Codes TotalLaparoscopicRobot Ventral Hernia Repair - All Codes TotalLaparoscopicRobot Inguinal Hernia Repair - All Codes TotalLaparoscopicRobot Please complete the above data collection for AIMIS review. We would like to collect the following: Total number of procedures, conversions to open, readmissions (note this will be first admits for same day surgery) and complications. As you can see, some of the complication data collection has been streamlined utilizing ICD 998 codes. Please detail what injury was obtained when utilizing 998.2 code since this code convers three complications we are looking for. Please report robotics procedures separately if possible. Hospital Name: Year of 2017Lap/Robot Cholecystectomy# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total Complications Lap/Robot Appendectomy# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total Complications Lap/Robot Small Bowel Resection# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total Complications Lap/Robot Nissen Fundoplication# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total Complications Lap/Robot Colon# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total Complications Lap/Robot Ventral Hernia Repair# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total Complications Lap/Robot Inguinal Hernia Repair# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total Complications GENERAL SURGERY- MEMBERSHIP LEVELS1. COE (Center of Excellence) – Physician/Hospital – Once an accredited AIMIS surgeon and hospital (or surgical center) has combined efforts and meets MIS standards, the center is recognized as a COE. The COE will have international recognition. Health plans provide unique financial rewards. • Member in “Good Standing” • Laparoscopic Designated Operating Room(s) • MEC to uphold designated surgeon minimum standards • Technology: Meets AI-MIS standards • Patient Care: Meets AI-MIS standards • Code of Conduct: Adheres to AI-MIS policies Authorization I understand that this information will be maintained for internal review purposes and will not be shares outside of the AIMIS organization without written authorization from the applicant, except to officers, directors, agents, attorneys, accountants, financial partners and lenders of AIMIS, to third parties who must gain access to such information in order to assist AIMIS in the conduct of its business (provided, however, such third parties acknowledge and agree to maintain the confidentiality of such information), and in order for AIMIS to comply with legal proceedings or court process. With my signature, I proclaim that all the information provided is accurate to the best of my knowledge. This application is valid for 12 months from date of receipt and with the option to renew membership. Hospital BiographyAccepted file types: pdf, doc. (maximum size: 2 MB)Current MIS Delineation of Privileges (if available)Accepted file types: pdf, doc. (maximum size: 2 MB)