GUIDELINES FOR CRITERIA AND CERTIFICATION RULES ANNEX - JAWDA Data Certification for Healthcare Providers - Methodology 2017.

Transcription

1 GUIDELINES FOR CRITERIA AND CERTIFICATION RULES ANNEX - JAWDA Data Certification for Healthcare Providers - Methodology 2017 December 2016 Page 1 of 14

2 1. Contents 1. Contents 2 2. General 3 3. Certification Requirements and Guidelines for Criteria 4 4. Weights and Scoring 9 5. Annual Certification Maintaining Validity of the Certificate Performance of Audits Management of Certificates Modification of Certification and Communication of Changes Special Requirements for Multi-Site Facilities Suspension, Reinstatement and Withdrawal of Certification Renunciation of Certification 14 Page 2 of 14

3 2. General 2.1 These rules constitute integrate the Contract between certification body (TASNEEF) and Healthcare Facilities. These Rules don t replace the Methodology 2017 but are part of the contractual requirements to achieve the JAWDA Data Certification. In this perspective, the rules describe identify criteria the Facilities can or must apply for the JAWDA Data Certification related to the HAAD Methodology 2017 and how facilities can apply for obtain, retain, renew and use this certification, as well as its possible suspension and revocation. 2.2 Certification is in accordance with HAAD Methodology dated December 2016 to facilities where Management System must be recognised as conforming. The Criteria of the certification are represented from the Methodology and other requirements of the compulsory reference standards or guidelines described in this document. 2.3 Certification is open to all Healthcare facilities in Abu Dhabi belonging to the following categories and encounters: Hospitals Medical Centres /Clinics TASNEEF is entitled to refuse requests for certification by facilities whose activities have been subject to restriction, suspension or proscription by a public authority. When TASNEEF declines an application, the reasons shall be communicated to HAAD and the facility CFO/CEO/COO or delegated authority. 2.4 This document provides also guideline to the Criteria applicable to the certification process because the JAWDA Data Certification is oriented to improve quality in the healthcare facilities. Quality means the ability to satisfy requirements of moral, material, social and economic nature, translated into stated requirements. The quality of the health service (intended as the ability to satisfy the associated needs) is the result of a: series of scientific, technical and technological, organizational, procedural, relational and communicational elements in which a determining role is carried on by the human variables (health operators and service customers in this concept is patients) that strongly interact in the realization processes, even more than in other activities also essentially based on human relations, such as education The elements to be considered in quality in health and associated achievement services are therefore numerous and complex for example through: adequate organization of the structure and suitable management of the primary and supporting services, which are reflected, though not strictly, in the ISO 9000 and JCI series; adequate definition of the "technical" content of the services provided (service specifications), which corresponds to a series of specialized standard references of which medical-scientific documentation and diagnostic-therapeutic protocols are particularly important; qualification of assigned personnel (basic training, applicative knowledge, human skills and ethics behavior), which is related to the mechanisms of recruitment, selection, training; medical-scientific reference documentation (Protocols, Procedures or Instructions, etc.) that are used to support the records. Page 3 of 14

4 2.5 The JAWDA Date Certificate issued pertains exclusively to a single healthcare facility identified by their license number. 3. Certification Requirements and Guidelines for Criteria 3.1 JAWDA Data Certification HAAD defines two key elements to quality in healthcare Reliability and Excellence: Reliability The systematic reduction in errors or untoward events defined in HAAD Standards Monitoring through self-checking or audits and inspections by HAAD or by bodies on its behalf. Excellence The continuous improvement, beyond minimum Standards, of clinical care delivery, customer satisfaction and cost-effectiveness. Underpinned by the routine collection, analysis and use of health data for routine clinical audit by Providers (and Departments) and Professionals. Driven towards continuous improvement through a clear pay for quality incentive system intention of improving clinical data quality thereby improving quality of patient care. To obtain JAWDA Data Certification the facility must: Have established a Management System and kept it active in total conformity with the requirements of the HAAD Methodology The management system is considered as being fully operative when processes, checkpoints and documented information are established for the three domains of certification as per below: Claim review Clinical Coding Process Review KPI Data Validation (relevant to Quality Indicators Data Submission and applicable only for hospitals) KPI Process Review (relevant to Quality Indicators Data Submission and applicable only for hospitals) 3.2 Claims Review Claims Review is one of the four components of the JAWDA Data Certification. Claims review is a validation process to review physician documentation against the submission of reported clinical coded data by all healthcare providers to build trust between payers and providers. JAWDA Data Certification will endeavor to strengthen the trust between payers and providers by: Creating a shared understanding of the facility s coding and physician documentation quality Page 4 of 14

5 Giving the payers confidence that a facility is coding and documenting accurately Providing the facility with recommendations to improve the quality of coding processes This involves the comparison of actual coding practices against agreed, documented, evidence based standards with the intention of improving clinical coding data quality thereby improving quality of patient care. The purpose of the claim review is to measure the medical record: to verify documented services provided to the patient, to verify the documented information describing the course of the patient s condition and treatment and to verify the validity of billable services Applicability Claims Review will be a mandatory requirement for all the healthcare facilities contracted with health insurance companies for providing healthcare services, including the lowest Evaluation and Management level of service Criteria (reference standards, methodologies, single standard s requirements): HAAD JAWDA Data Certification Methodology 2017 (compulsory) CPT 4 th Edition procedure (compulsory) ICD-9-CM Official Guidelines for Coding and Reporting (compulsory) ICD-9-CM Coding Manual for Hospitals & Other Healthcare Institutions, published by Health Authority- Abu Dhabi (Refer to: Appendix A) (compulsory) ICD-10-CM Official Guidelines for Coding and Reporting (compulsory if applicable) HAAD CLAIMS & ADJUDICATION RULES V2012 and Appendices Audit checkpoints Claim level audit on random samples as per the guidelines mentioned in the methodology. The audit will focus on scoring: a. Accuracy (ICD-9-CM, ICD-10-CM, CPT 4th Edition for all services) b. Completeness ((ICD-9-CM, ICD-10-CM, CPT 4th Edition for all services) Accuracy claims review will output an Accuracy Score by assignment and reporting of only the codes and data that are clearly and consistently supported by the health record documentation and in accordance with applicable code set and abstraction conventions, rules, and guidelines. Claims reviews will also identify clinical coding submission or improper documentation practices intended to inappropriately increase reimbursement from payers or influence payer adjudication rules. Completeness analysis contributes to recommendations on claims coding practices and does not affect the passing criteria. It includes missing diagnoses and procedures that would have provided more detail on the condition or status of the patient but would not have an impact of higher outcome of reimbursement from payer for the services provided. The Completeness scoring will help determine and/or recommend improvements with regards to the reporting of clinical coding and/or deficiencies in physician documentation. Once each medical record has been scored, a mean average score will be calculated for each place of service. (E.g. Inpatients-DRG, Day-case, Outpatient clinics, Emergency and Home Care). Page 5 of 14

6 3.3 Clinical Coding Process Review Successful processes should be understood and followed by all involved. The facility will be rated on the facility s understanding and adherence to their process. The process of adherence check is to understand the deficiencies in the Management System Applicability Clinical Coding Process Review will be a mandatory requirement for all the healthcare facilities contracted with health insurance companies for providing healthcare services, including the lowest Evaluation and Management level of service Criteria (reference standards, methodologies, single standard s requirements): HAAD JAWDA Data Certification Methodology 2017 (compulsory) HAAD Coding Manual for Hospitals & Other Healthcare Institutions (compulsory) HAAD CLAIMS & ADJUDICATION RULES V2012 and Appendices American Medical Association (AMA) (compulsory) Centers for Medicare & Medicaid Services (CMS) manual system WHO Medical record standards Electronic Code of Federal Regulations American Health Information Management System (AHIMA)- Body of Knowledge American Hospital Association (AHA) Coding Clinics (compulsory when applicable) HAAD Providers Policy Manual ASTM E (2014) Standard Guide for Confidentiality, Privacy, Access, and Data Security Principles for Health Information Including Electronic Health Records ASTM E (2010) Standard Guide for Amendments to Health Information ISO 9001:2015(paragraphs 7.2, 7.5, 8.0 in relation to the validation concept, 9.0, 1 Joint Commission - International Accreditations Standards for the Hospitals 5th Edition (Healthcare Organization Management Standards QPS series and Management of Information MOI. Series ) Audit checkpoints Facility will be audited against the following aspects and utilizing the compulsory criteria or suggested or equivalent: Coding Process Flow chart reflecting the process followed in the facility Policies review - such as Coding Practice Policies, Healthcare Documentation policies Coder Credentials and Continuous education validation Orientation or Training policy Level of Implementation of policies through four departments Mandatory Certified Coder One of the following criteria must be met to pass the JAWDA Data Certification audit: have a Certified Coder with active status of AAPC or AHIMA (or) evidence of contracted outsourcing for coding services Action plan to train and certify a coder within the facility in a specific time (maximum 1 year) Page 6 of 14

7 The process review will include: Gaps or deficiencies in the data submission process flow Record of Coder certification validation based on submitted proofs Creation and updating of processes, policies relevant to clinical coding Review of Compliance practices for coding Review of control and modification of documents Adherence check and provide with the areas for improvement, and recommended trainings Identified non-conformities to policies and process flow 3.4 KPI Validation for Collection and Submission of Quality Indicators The vision for the Health System in Abu Dhabi is to provide access to high quality healthcare services to all. To achieve the vision a common language was developed and a standardized way of exchanging data. KPI validation is a method to verify if the information collected from the Hospitals for HAAD Quality Performance KPI Profile program has an objective evidence to confirm that the requirements which define the intended use have been met. As healthcare moves forward with initiatives such as quality-driven reimbursement and clinical quality measure reporting, both organizations and physicians must provide justification for patient care and demonstrate quality outcomes Applicability Only for hospitals registered from the Health Authority in the JAWDA Program for Quality Indicators and metrics Criteria (reference standards, methodologies, single standards requirements): HAAD JAWDA Data Certification Methodology 2017 (compulsory) Waiting time indicators from JAWDA program (compulsory) ISO 9001:2015 (paragraphs 7.2, 7.5, 8.0 in relation to the validation concept, 9.0, 10.0) HAAD reference Quality Performance KPI Profile - Dec (compulsory) HAAD reference. Per Circular CEO 38/ 12 (compulsory) Joint Commission - International Accreditations Standards for the Hospitals 5th Edition (Healthcare Organization Management Standards QPS series and Management of Information MOI. Series ) Audit Checkpoint The validity will check against matching of results submitted. The validation may undertake one or all the category of established indicators (e.g. waiting time indicators, adverse incidents and outside critical care cardiac arrest). Certification body will verify the validity and on time submitted data. The validation will match the internal reports of the facility against the reports sent to HAAD. Mystery shopping could be performed from the certification body to validate the reports. Every year HAAD will define the scope of KPI Validation including or excluding indicators. 3.5 Process Review for: KPI Quality Indicators (applicable only to Hospitals) Page 7 of 14

8 The aim of this quality measure is to improve the validity of KPI data collection and submission processes. This will add an extra layer of prioritization for the quality at the healthcare providers level. Patient safety, clinical effectiveness and patient experience are recognized as the main pillars of quality in healthcare. Healthcare providers will be evaluated on processes in planning for data collection and submission. The process approach is the most relevant aspect of any quality system. The Abu Dhabi Health Authority orients its methodology to it for better control of any healthcare outcome. A process is a set of activities that are interrelated or that interact with one another. Processes use resources to transform inputs into outputs. Processes are interconnected because the output from one process often becomes the input for another process. Organizational processes should be planned and carried out under controlled conditions. An effective process is one that realizes planned activities and achieves planned results (e.g. as per the ISO 9001:2015 concept) Applicability Only for hospitals registered from the Health Authority in the JAWDA Program for Quality Indicators Criteria (reference standards, methodologies, single standard s requirements): HAAD Methodology 2017 (compulsory) Waiting time indicators from JAWDA program (compulsory) ISO 9001:2015 (paragraphs 7.2, 7.5, 8.0 in relation to the validation concept, 9.0, 10.0) Audit Checkpoints HAAD reference Quality Performance KPI Profile - Dec (compulsory) HAAD reference. Per Circular CEO 38/ 12 (compulsory) The facility must make all necessary information available to TASNEEF for KPI planning for data collection and submission. The following to be considered: Robustness: Quality Lead KPI Process Awareness Data Collection Plan Data Collection Tools Data Collection Methodology Data Submission Process and Timeliness Data Integrity and Backup plan Data collection trails (Audit trails) Communication log for feedbacks and performance improvements Submission Log Quality Governance: Regular quality monitoring system Staff Awareness of quality governance, data collection, improvement Page 8 of 14

9 Risk management process to control risks that could prevent the organization s achievement to the planned objectives Customer complaints process management Internal Audits and Non-conformance processes Structural management review process to review the performance of overall quality system Facility Type Medical Centers /Clinics /Home care centers 4. Weights and Scoring The final score will be weighted per the facility type as shown in the below tables. The passing scores for process review of clinical coding, process review for KPI and KPI data validation will be communicated annually from HAAD. Facility Type: Medical Centers / Clinics - Table 4.1 Domain Domain Details Weights Final weights Over all weights Outpatient (100) 50% Claims Review Day case* (100) 50% Claims review Score for % 80% Clinical Coding Process Review CENTERS / CLINICS -DETAILED SCORING WEIGHTS Process flow map (15) 15% Coding Policies (5+35) 40% Coder Credentials (20) 20% Orientation/Training (5) 5% Compliance-4 departments (20) 20% Clinical Coding Process Review Score for 100 FINAL JAWDA CERTIFICATION SCORE 20% 20% Facility Type Hospitals Facility Type: Hospitals Table 4.2 HOSPITALS -DETAILED SCORING Final Final Domain Domain details Weights Score Points weights Score Outpatient % Emergency % Claims Review Inpatient % Day case % Home Health care % Claims review Score Clinical Coding Process Review Clinical Coding Process Review Score KPI Process review Process flow Map Clinical Coding Policies Review Coder Credentials Orientation/Training Compliance-4 departments Robustness 50% Quality Governance 50% KPI Process review Score KPI Data Validation Score Data Validation (9-Indicators-WT) FINAL JAWDA CERTIFICATION SCORE 100% Page 9 of 14

10 Example1: Details of scoring for the medical centers and clinics will be as shown in the below table as an example: Table 4.3 CENTERS / CLINICS -DETAILED SCORING Facility Type Domain Domain Details Weights Score Points Over all weights Final Score Outpatient (100) 50% Claims Review Day case (100) 50% Claims review Score for % 69% Medical Process flow map (15) 15% Centers Clinical Coding Coding Policies (5+35) 40% /Clinics/ Process Coder Credentials (20) 20% Home care Review Orientation/Training (5) 5% Centers Compliance-4 departments (20) 20% Clinical Coding Process Review Score for 100 FINAL JAWDA CERTIFICATION SCORE % 17% 86% Facility Type Hospitals Example 2: Details of scoring for the Hospitals will include KPI Indicators validation along with Clinical Coding as shown in the below table as an example: Table 4.4 Domain Domain details Weights Score Points Claims Review Claims review Score Clinical Coding Process Review KPI Process review Score KPI Data Validation Score HOSPITALS -DETAILED SCORING Over all weights Final Score Outpatient % Emergency % Inpatient % Day case % Home Health care % Process flow Map Clinical Coding Policies Review Coder Credentials Orientation/Training Compliance-4 departments Robustness 50% Quality Governance 50% Clinical Coding Process Review Score KPI Process review 100% Data Validation (9-Indicators-WT) FINAL JAWDA CERTIFICATION SCORE Page 10 of 14

11 5. Annual Certification Facilities wishing to obtain certification for their JAWDA must provide TASNEEF with their main facility data and site location by filling in all parts of the APPLICATION FORM on TASNEEF website at The APPLICATION FORM requires information to be provided on: Name of the Facility HAAD License No. Facility Settings Contact Details Other mandatory fields This information should be provided by an authorized representative of the applicant organization. 5.1 Contract formation o TASNEEF will open file with the provided information and prepares a suitable contract as per the Tier system applicable to the facility, which is provided by HAAD, and contract will be sent to the authorized representative for certification. Prior to performing the audit, TASNEEF makes sure: a) there is sufficient information concerning the applicant facility and its management system to perform the audit; b) certification scope is clearly established and documented and are sent to the applicant facility; c) every difference of interpretation between TASNEEF and the applicant facility has been eliminated; Acceptance of the contract is made by sending TASNEEF the specific form attached to the contract and any other document per which certification is requested. On receipt of the application for certification and the relative annexes and having ensured they are complete, TASNEEF will send the facility written acceptance of its application. The agreement signed between TASNEEF and the facility includes: 1) Certification fee 2) Information on fee for Follow-up Audits if applicable to the facility as mentioned in the contract and as per the applicable General terms and Conditions 3) After the satisfactory completion of the initial audit and after validation by TASNEEF, a Certificate of Conformity with the reference standard, if meet the criteria, will be issued. 6. Maintaining Validity of the Certificate The facility must ensure its System continues to comply with the Methodologies and other applicable reference standards or regulatory document. The facility must record any complaints / claims and the relative corrective action implemented and must make these records available together with the corrective action taken to address the identified deviations. Page 11 of 14

12 TASNEEF also reserves the right to perform additional audits based on the impact of identified deviations in the processes. Also, reserves the right to perform and charge Re-audits on failed facilities. May conduct a follow-up audit to confirm that the major deviations identified during the initial audit have been corrected by facility as per the action plan. Action plan should be sent by the facility to TASNEEF giving the details of action for corrections with-in a week after initial audit. TASNEEF shall conduct a Re-audit on failed facilities as Phase-1 audit to verify the corrected Processes as per the action plan within two months duration after failure. A mandatory uninformed or surprise audit on Claims review will be done on the failed facilities after completion of first phase of Re-audit with-in six months from Phase-I. If the facility refuses without a justified reason, TASNEEF may decide to suspend/withdraw certification. 7. Performance of Audits 7.1 General An Audit Plan is drawn up for each audit according which is sent to the customer facility in good time. TASNEEF also uses the Audit Plan to inform the Facility of the names of the auditors and technical experts appointed to perform the audit, chosen based on the skills required to perform the audit; the Facility may object to the appointment of these auditors provided it gives a justified reason, for example regarding conflict of interests. The audit has the following objectives: a) Determination of the conformity of the client s management systems, or part of it, with audit criteria; b) Evaluation of the ability of the management system to ensure the client organization meets applicable and contractual requirements; NOTE: JAWDA Data Certification audit is not a legal compliance audit. c) As applicable, identification of areas for potential improvement of the management system. The Audit Plan indicates the tasks assigned to each auditor. Specifically, for each facility: a) the structure, policy, processes, records and relative documents to the applicable Management system must be examined and checked; b) it must be established whether these satisfy the requirements applicable to the scope of certification; c) it must be established whether the processes and documented information are drawn up, implemented and kept efficient, to nurture trust in the Facility's management system; d) every inconsistency between the organization or facility s policy, objectives, goals and the result obtained must be reported to the facility (authorized representative) to allow for appropriate action. e) Collecting audit evidences 7.2 Report A copy of the written report will be delivered to the authorized representative, responsible for the facility. The original audit report is owned by the certification body. Page 12 of 14

13 The facility may indicate any reservations or comments concerning the findings by the TASNEEF auditors in the relative space in the audit report. The report will include: Scoring for claims review Scoring for Process Review Clinical Coding Scoring for Process Review KPI (applicable only to Hospitals in JAWDA program) Scoring for KPI data validation (applicable only to Hospitals in JAWDA program) Recommendations for improvements After analyzing the reasons for any major or minor observations indicated in the above report, the Facility must, within the data indicated on the report, inform TASNEEF of its proposals for handling the observations, as well as the corrective action required and the dates envisaged for its implementation. In the event of major observations (type A findings) the certification process requires an extra visit for process review; this follow-up audit must be performed within two months to check the effectiveness of the proposed corrective actions; if this audit is successful the certification process will be resumed. The auditing team may decide to perform any follow-up audit on site or on the documents, depending on the type of corrective action involved. All costs relative to any follow-up audit deriving from shortcomings in the Management System will be charged to the facility. 8. Management of Certificates 1. The validity of the certificate is based on the scoring achieved by the facility 2. The validity of the certificate, could be subjected to the results of the subsequent audits. 3. The validity of the certificate may be suspended, withdrawn or relinquished 9. Modification of Certification and Communication of Changes 9.1 The facility must promptly inform TASNEEF of any changes in factors that may affect the capacity of the Management System to continue to satisfy the requirements of JAWDA Data Certification. These requirements concern, for example, modifications to the legal, commercial, facility or ownership status. TASNEEF reserves the right to perform additional audits on the facility if the modifications communicated are considered particularly significant in regards maintaining the conformity of the Management System with the requirements of the reference standard and of these rules or to review the economic conditions for the possible modification of the contract. 9.2 TASNEEF promptly informs the facility of every change in the methodology, reference standards or certification rules. 10. Special Requirements for Multi-Site Facilities If a provider operates on more than one facility and a single contract is required, audit activities will be performed for each facility anyway; Page 13 of 14

14 Note: in case of centralised system, the auditor will verify if all facilities are following same methods and procedures. 11. Suspension, Reinstatement and Withdrawal of Certification The validity of the certificate of conformity may be suspended as indicated in GENERAL TERMS AND CONDITIONS and in the following specific cases: if the Facility refuses to allow the scheduled audits to be performed at the required frequencies; if observations are found in the management system which have not been corrected within the time limits established by TASNEEF if the facility does not observe the deadlines established for the communication of corrective actions, following observations/observations indicated on the audit report; for evidence that the facility does not guarantee the respect of the laws and regulations applicable to the supplied services or activity if any justified and serious claims received by TASNEEF are confirmed. The facility may also make a justified request to suspend certification, normally for not more than six months and in no case after the date of expiry of the certificate. This suspension will be notified in writing, stating the conditions for re-instating certification and the date by which the new conditions are to be complied with. Revocation of the certificate of conformity may be decided in the following specific cases: if the facility does not accept the economic conditions established by TASNEEF due to a modification in the contract tariff, approved with HAAD for every other major reason, at TASNEEF 's discretion, such as the proven incapacity of the system to pursue its objectives of complying with legislative, contractual requirements. Withdrawal of the Certificate of Conformity is notified in writing to the Facility and made public in HAAD website Any facility which, following revocation of its Certificate, wishes to be re-certified, must submit a new application and follow the entire procedure all over again. 12. Renunciation of Certification A certified facility may send formal communication of renunciation of certification to TASNEEF in case of business termination, before the expiry of the certificate. Upon receipt of this communication, TASNEEF starts the procedure for invalidating the Certificate. Within one month from the date of the communication, TASNEEF updates the validity status of the certificate. Page 14 of 14