American Dental Association Peer Review Recognition Program

Transcription

1 American Dental Association Peer Review Recognition Program Criteria and Best Practice Standards

2 TABLE OF CONTENTS Introduction... 3 Peer Review Recognition Program... 3 Submission Process... 4 Guidelines for Submission Required Criterion A. MANUAL AND TRAINING B. COMMITTEE COMPOSITION C. PROCESS Optional Criterion A. MANUAL AND TRAINING B. COMMITTEE COMPOSITION C. PROCESS Appendix A: Checklist for the Evaluation Criteria Appendix B: Checklist of the Documents to be Submitted: Appendix C: Rules and Guidelines for Use of the ADA Peer Review Recognition Program Signage P a g e

3 Introduction The American Dental Association supports the profession's peer review programs by providing guidelines for establishing peer review programs documented within the ADA s manual, Peer Review in Focus. The manual is reviewed on a regular basis to maintain the most current and up-to-date information. State and local dental societies are encouraged to use the manual as a guide to structure their own peer review program. Peer Review in Focus and the peer review flyer, brochure and mediation checklist are available for download at In order to further support states to demonstrate the high standards established for their peer review programs, the ADA, through its Council on Dental Benefit Programs (Council) is launching the new Peer Review Recognition Program. The Peer Review Recognition Program (PRReP) is one of the Council s newest endeavors to provide an easy framework for review of states peer review program structure and performance and ensure that best practices are incorporated into the administration of peer review programs. While individual state practice acts and other laws would ultimately influence program structure within each state, there are several processes in administering the program that can be standardized, and in some cases improved to ensure integrity of peer review programs. The criteria used within the recognition program are derived from the ADA s Peer-Review in Focus Guidelines. Peer Review Recognition Program State peer review programs that have been recognized through this program will receive: an ADA Peer Review Recognition Program signage to be used in the state/local website/ promotional materials. ADA peer review training and promotional materials that have been developed by the Council on Dental Benefit Programs. free registration to attend webinars that will be hosted by the ADA annually to facilitate aimed towards cross-state learning and emerging issues. 3 P a g e

4 The PRReP criteria should not be considered as legal or professional advice, or as creating a standard for the peer review process. Rather, each state peer review program must consult with its own legal counsel to assure that it complies with applicable law, bylaw provisions and insurance protection. Submission Process Participation in the Peer Review Recognition Program is completely voluntary. The review to deem recognition will be conducted by the ADA s Council s Subcommittee on Quality Assessment & Improvement (QA&I). The review process will entail a thorough review of the submitted documentation in support of the criteria listed below. There are ten required and five optional criteria. States will be required to submit documents and evidence in support of ALL REQUIRED CRITERIA to be considered for the PRReP. These criteria fall under three main domains of manual and training, committee compositions and peer review process. A checklist is available below in Appendix A. The state peer review program is required to submit all the materials for performance evaluation to the Center for Dental Benefits, Coding and Quality to ensure the fulfillment of each of the criterion listed below. If state laws or other valid reasons exist that prevent the state from meeting a particular criterion, adequate justification seeking exception should be included within the submission to enable the Council to consider the exception. Guidelines for Submission a. State peer review programs are requested to submit a letter of interest addressed to the Council on Dental Benefit Programs via at ojhad@ada.org or mail at American Dental Association 211 E. Chicago Ave Chicago, IL Attn: Dr. Diptee Ojha b. This program is applicable to only State Peer Review Program and not their local constituent programs. c. Following initial review, the Council may request additional information to facilitate the process of evaluation. All of the materials must be submitted in entirety within 90 days of the start of the recognition process. 4 P a g e

5 d. The evidence requested for fulfillment of the criterion should be in alignment with the checklist provided within this document including justifications for any exceptions. A checklist for the submission to aid the individual peer review program is provided as an Appendix B. e. All documentation will need to be sent in at least 90 days prior to the CDBP Council meetings which take place usually in April and November of every calendar year. Upon completion of review from the QA&I Subcommittee, ultimate approval will be provided by the full Council. f. Upon the acknowledgement of receiving the ADA Peer Review Recognition Program from the Council, the state will be allowed to use ADA Peer Review Recognition Program signage on their webpage and promotional material, within the guidelines stipulated by the ADA. It is the state peer review program s responsibility to ensure it complies with the ADA guidelines. These guidelines are listed in Appendix C. g. This ADA Peer Review Recognition Program will be valid for three years, following the time of approval. Individual programs will be contacted approximately 6 months prior to expiration of the current ADA Peer Review Recognition Program period to complete the requirements for the next 3 year ADA Peer Review Recognition Program period. In order for the state peer review programs to renew their ADA Peer Review Recognition Program after the three year expiration date, the individual programs will be required to submit updated information for review. h. There will be no fees associated with the recognition process. This is subject to change. i. Should the state peer preview program fail to provide all required documentation; the program will be required to initiate a new submission after 6 weeks. j. The ADA reserves the right to make changes to the required ADA Peer Review Recognition Program document at any time at its sole discretion. k. Staff will provide initial review of documentation provided by State societies. The QA&I Subcommittee will do full review of provided documentation and make recommendation to the Council. The full Council has the final decision on the application. l. If the state fails to submit all the documents pertaining to each REQUIRED CRITERIA, the state will be contacted by staff to inform them of which criteria they are not meeting and ask that they resubmit proper documentation to show that the state is following the said criteria. After staff receives proper documentation, the review process will resume. 5 P a g e

6 1. Required Criterion 1. A. MANUAL AND TRAINING Criteria 1. A. i: The state maintains a published peer review manual that takes into account the state laws in establishing standard processes. Description: The ADA provides a detailed manual to guide peer review programs. Many aspects of the program can be impacted by state laws and practice acts. All state societies should have a clear manual that takes into account the state laws and is based on the principles described within the ADA s peer review guidelines. Required Evidence of Meeting Criterion: a) State s published manual b) Copies of all the relevant forms and documents used in the peer review process in entirety e.g.: sample letters used for communication with the patient, dentist, committee members, consent forms and release forms Criteria 1. A. ii: The state peer review manual is reviewed periodically Description: State societies should have an established policy/process to review and update the manual and other documentation. Required Evidence of Meeting Criterion: a. A copy of the review process b. Documentation of the timeline of the review c. Date of last review of manual d. A copy of the individual s names and credentials who oversees the review process Criteria 1. A. iii: Peer review process description should be available for patients to review. Description: Patients should have access to a concise and easy to understand description of the peer review program and the process involved. This facilitates agreement and helps manage expectations as patients choose to resolve their disputes through peer review. Required Evidence of Meeting Criterion: a. A copy/link of the letter/brochure that is sent to the patient that outlines either/or both the mediation and the clinical review process 6 P a g e

7 Criteria 1.A.iv: Peer review training should be offered to the staff and the committee members on periodic basis. Description: At least an annual training schedule should be established including staff from both state and local levels to ensure that the procedures and processes in place are well understood by staff to effectively support peer review committees. Required Evidence of Meeting Criterion: a. Documentation of training schedules b. Documentation of training materials c. A copy of the list of individuals contact information and credentials who provided these trainings d. A copy of the list of individuals who most recently received the training 1.B. COMMITTEE COMPOSITION Criteria 1.B.i: States are required to have a permanent peer review committee. Description: The peer review committee should be a permanent committee of the dental society with appropriate status and ties to other related committees. It can be formed as a freestanding committee or, alternatively, a subcommittee of the body within the society that concerns itself with dental care programs. In some states, the peer review and ethics committees operate under a single organizational umbrella. Required Evidence of Meeting Criterion: a) A copy of the structure of the peer review committee with details on the size and the formation Criteria 1.B.ii: Committees are required to be comprised of experienced and qualified practitioners. Description: The committee membership should be composed primarily of general practitioners who have the qualifications and experience to render a considered opinion as to the dental standards of the community. The appointment of a layperson to serve on the peer review committee is encouraged. An 7 P a g e

8 individual who serves on a constituent society body responsible for hearing appeals should be excluded from serving on a component committee because of the potential conflict of interest. Similarly, individuals who have an interest in the outcome of the case that might cloud their impartial judgment should be excluded. Whenever possible, local society officers should also refrain from participation. Required Evidence of Meeting Criteria: a) A copy of the list of the committee members contact information and credentials with details of their background information (i.e. CV or Resume) b) Policy regarding inclusion of lay persons on peer-review committees Criteria 1.B.iii: States should have errors and omissions or directors and officers liability policies that cover members serving on the committees. Description: Ensuring adequate protection for peer review committee members is essential to mitigate legal concerns for the society and the peer review volunteers. Required Evidence of Meeting Criteria: a. Attestation from state society that liability protections are in place for the society and its volunteers. 1.C. PROCESS Criteria 1.C.i: States should have standardized forms to use through the process including HIPPA consent forms and other medical record release forms. Description: The appendices to the ADA s Peer Review in Focus Manual contain sample letters and forms that illustrate administration of the review process, arranged in the order they would normally be used. Each state dental society should review this sample process and the sample forms with its attorney and make any changes needed to conform these documents to applicable federal, state, or local law or conditions. Required Evidence for Meeting Criteria: a. Copies of all the forms used in compliance with the HIPPA laws 8 P a g e

9 Criteria 1.C.ii: States are required to have an established appeal process. Description: All peer review programs should allow for an appeal process when certain criteria are met. The request for an appeal should be sent in writing to the state society's peer review committee or other appropriately designated body. The basis for the appeal should be stated in the request and may include: Members of the peer review committee were not qualified to decide the case. Proper procedures were not followed in the process. Additional information has become available which was not considered by the deciding committee, either because it was not available at the time of the committee's review, or because for some good cause it was not presented to the committee. The decision of the committee appears contrary to the information presented. Required Evidence for Meeting Criteria: a. Copies of policy/procedures regarding appeal (if not already included in the Manual Appeal request form; Criteria 1.C.iii: States must ensure that all mediation/ peer review of cases must be completed within 90 days of process initiation. Description: The total peer review process, including mediation, is generally completed within 90 days. Any records obtained from the dentist s office are returned to the dentist and the documentation of the case is sent for file to the constituent dental society. The peer review program maintains the record for the length of time required by state laws. Required Evidence for Meeting Criteria: a. Documentation of the peer review process; from the initiation of a case by a patient or a third party payer until the decision from the peer review committee 9 P a g e

10 2. Optional Criterion 2.A. MANUAL AND TRAINING Criteria 2.A.i: The state maintains a conflict of interest policy. Description: An individual who serves on a peer review committee should be excluded from serving on a component committee because of the potential conflict of interest. Similarly, individuals who have an interest in the outcome of the case that might cloud their impartial judgment should be excluded. Required Evidence of Meeting Criterion: a. A copy of the conflict of Interest policy 2.B. COMMITTEE COMPOSITION Criteria 2.B.i: Committee members that serve on peer review committees should be appointed to staggered terms in order to ensure continuity. Description: Terms on the committee should be staggered to ensure continuity of experience. Required Evidence of Meeting Criteria: a. Copy of the policy pertaining to the term length. Exception apply. In case of an exception, the peer review programs are required to submit additional documentation to justify the exception b. Copy of list of individuals on current committee and their terms Criteria 2.B. ii: States are required to have a formal process of educating the peer review committee members on a regular basis. Description: Irrespective of whether the program is structured to only include mediation or both mediation and clinical review, all state societies that administer the programs should have a process for training committee members on a regular basis potentially once every 2 years. Required Evidence of Meeting Criteria: a. Documentation of the training schedules for state committee members b. Copies of the training materials used to educate the committee members 10 P a g e

11 2.C. PROCESS Criteria 2.C. i: States must track program performance data. Description: Looking at the trends in the cases that have been handled in the past and seeing whether they fall within the standards that the committee has set, establishes quality of the program and can also be used to identify and proactively mitigate any programmatic issues. De-identified program performance data should be presented and discussed with the peer-review committee at least annually. Required Evidence for Meeting Criteria: a. Evidence of a secure database maintaining case information b. Documentation of recent data queries to assess performance. Examples of performance metrics are listed below: Percentages of cases resolved within 90 days of case initiation Percentages of cases that were reviewed within 45 days of complaint filed Percentages of cases those were resolved through mediation vs. clinical review Criteria 2.C.ii: States should require member dentists to participate in and abide by peer review decisions. Description: To analyze the exposure of dental society peer review under the federal antitrust laws, it is necessary to determine what type of peer review a society conducts. Generally, there are three types: Mandatory - all member dentists must participate in peer review and abide by the decision of the peer review panel. Participatory - all members are required to participate in peer review, but compliance with the decision is optional. Optional - cooperation with the peer review panel and compliance with any order or recommendations is voluntary. Clear policies should be made available to ensure members are aware of the mandatory policy. Required Evidence for Meeting Criteria: a. Copy/Link to the policy that outlines the participation compliance 11 P a g e

12 Appendix A: Checklist for the Evaluation Criteria Required Criteria Criteria Documentation Please check the box if documentation present i. The state maintains a published peer review manual that takes into account the state laws in establishing standard processes. ii. The state peer review manual is reviewed periodically. iii. iv. Peer review process description should be available for patients to review Peer review training should be offered to the staff and the committee members on periodic basis v. States are required to have a permanent peer review committee. vi. Committees are required to be comprised of experienced and qualified practitioners. vii. viii. States should have errors and omissions or directors and officers liability policies that cover members serving on the committees. States should have standardized forms to use through the process including HIPPA consent forms and State s published manual Copies of all the relevant forms and documents used in the peer review process in entirety e.g. sample letters used for communication with the patient, dentist, committee members, consent forms and release forms A copy of the review process Documentation of the timeline of the review Date of last review of manual A copy of the individual s names and credentials who oversees the review process A copy/link of the review process that is sent to the patient that outlines either/or both the mediation and the clinical review process Documentation of training schedules Documentation of training materials A copy of the list of individuals contact information and credentials who proved these trainings A copy of the list of individuals who most recently received training A copy of the structure of the peer review committee with details on the size and the formation A copy of the list of the committee members contact information and credentials with details of their background information (i.e. CV or Resume) Policy regarding inclusion of lay persons on peerreview committees Attestation from state society that liability protections are in place for the society and its volunteers. Copies of all any form used in compliance with the HIPPA laws. 12 P a g e

13 ix. other medical record release forms. States are required to have an established appeal process. x. States must ensure that all mediation/per review of cases must be completed within 90 days of process initiation Copies of policy/procedures regarding appeal (if not already included in the Manual Appeal request form /Peer_Review_Manual_New.ashx) Documentation of the peer review process; from the initiation of a case by a patient or a third party payer until the decision from the peer review committee Optional Criteria i. The state maintains a conflict of interest policy. ii. Committee members that serve on the peer review/ mediation review should be appointed to staggered terms in order to ensure continuity. iii. States are required to have a formal process of educating the peer review committee members on a regular basis iv. States must track program performance data. v. States should require member dentists to participate in and abide by peer review decisions. A copy of the Conflict of Interest policy Copy of the policy pertaining to the term length. Exceptions apply. In case of an exception, the individual peer review program are required to submit additional documentation to justify the exception Copy of list of individuals on current committee and their terms Documentation of the training schedules for committee members Copies of the training materials used to educate the committee members Evidence of a secure database maintaining case information Documentation of recent data queries to assess performance o Percentages of cases resolved within 90 days of case initiation o Percentages of cases that were reviewed within 45 days of complaint filed o Percentages of cases those were resolved through mediation vs. clinical review Copy/Link to the policy that outlines the participation compliance 13 P a g e

14 Appendix B: Checklist of the Documents to be Submitted: Cover Page: Name of the Organization Submitting for Performance Recognition Table of Contents Organization Information Name Address (Complete contact information including mailing address, phone numbers and the web page URL) Name and contact information of the person submitting for Peer Review Recognition Program on behalf of the Organization Summary of the Submission Brief summary of the organization and its peer review program List of all the documents being submitted Signed Copy of the Rules for Use of ADA Peer Review Recognition Program Signage 14 P a g e

15 Appendix C: Rules and Guidelines for Use of the ADA Peer Review Recognition Program Signage Please sign and date the following. Use of the American Dental Association (ADA) Peer Review Recognition Program Signage and Statements are governed by the following rules and approved by the ADA Council on Dental on Dental Benefit Programs (Council): 1. The ADA Peer Review Recognition Program signage shall not be used until after the program has been completely evaluated by the ADA and has been notified in writing of being awarded the ADA Peer Review Recognition Program. 2. The ADA Peer Review Recognition Program signage may be used on the individual state and local dental society peer review program website and in advertising/ promotional material for only the Peer Review Program. 3. It is the individual peer review program and State and Local dental society s responsibility to ensure that the advertising/ promotional material for the ADA Peer Review Recognition Program signage comply with this guideline. 4. The ADA Peer Review Recognition Program signage is NOT to be used in place of or instead of the ADA Seal of Acceptance. 5. The ADA Peer Review Recognition Program signage may not appear in conjunction with the seal/ signage of any other investigative group, or with any symbol likely to confuse the public or the member of the State and Local dental society by instilling a belief that it constitutes a seal or symbol of any other designation, unless prior written approval for such display has been obtained from the Council. 6. The ADA Peer Review Recognition Program signage shall be legible and shall not be altered in any manner. 7. In the event an individual peer review program s performance evaluation expires, the ADA Peer Review Recognition Program award is no longer valid and the use of the signage should also be discontinued immediately. Exception to this rule lies in the event the individual peer review program re-applies for their program performance evaluation. 8. The ADA Peer Review Recognition Program signage is owned by the American Dental Association. This program complies with the rules of the use of the ADA Peer Review Recognition Program, governed by the American Dental Association s Council on Dental Benefit Programs. Sign Date 15 P a g e