CPQ Overview

On the pulse of the healthcare sector

WHAT IS CPQ:

GOAl Of CPQ

Dubai Healthcare City (DHCC) established the Centre for Healthcare Planning and Quality (CPQ), as an independent regulating body responsible for building the quality management infrastructure within DHCC.

CPQ provides a wide range of products and services, including the following:

• Planning of clinical services• Design review• Licensing of Healthcare Operators (HCOs) , Healthcare Professionals (HCPs) and academic and

research activities within DHCC• Provision of clinical quality management assessment and training• Maintenance, analysis and distribution of healthcare information and statistics• Customer Protection Unit• Pharmacy Services Unit

The goal of CPQ is to support and encourage ongoing, high-quality improvements in every aspect of healthcare delivery within DHCC.

CPQ is committed to ensuring the highest level of patient safety, quality management and support services for training staff, developing systems, and monitoring quality standards. All HCOs and HCPs working within DHCC are required to meet DHCC’s quality requirements by implementing processes that support ongoing, high-quality improvements.

Continuous development is critical for all HCPs who embrace excellent standards of care. CPQ ensures that HCPs within DHCC have direct access to continuing medical and clinical education programmes via a global network of experts.

CPQ is building the quality management infrastructure that will make DHCC a major focal point for healthcare delivery and medical education. CPQ will also ensure that healthcare services provided within DHCC are comprehensive and aligned with regional demand.

PlAnnInG And SPeCIAl PrOjeCTS dePArTmenTregulatory framework

facility licensing

Step 1

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Step 2

Complementary and Alternative medicine (CAm)

PlAnnInGfunCTIOnS

The Planning Department (PD) plans clinical services to ensure integrated and balanced healthcare delivery throughout DHCC. The PD’s role is to assist you in understanding the current and upcoming operational facilities. This includes services planned for Dubai Healthcare City and the distribution of these services to ensure the continuity and integration of healthcare.

Adhering to the best international standards, CPQ has been keen in developing a world class framework of clinical Regulations & Rules governing Healthcare Professionals and Healthcare Operators working in DHCC.

Currently, there are 10 governing Regulations in DHCC. The purpose of the Regulations is to set out the governance framework under which registered companies, Licensed Healthcare Professionals, Licensed CAM Professionals, and Licensed Healthcare Operators operate in DHCC.

Facility Licensing provides a consultative environment in which applicants are guided through regulatory processes required to operate in DHCC as a healthcare operator (HCO) or commercial entity. Typical process steps are as follows:

An initial application form is accurately completed and submitted with supporting documentation. This form introduces the applicant and provides the necessary business information for CPQ to begin the application process.

PC review decisions are advised to applicants including approval, rejection and requests for further information. A provisional approval letter for applied services provides the pre-requisite for an applicant to complete leasing or purchasing requirements with DHCC, and defines restrictions and/or conditions where applicable.

Approvals are categorized by the facility practice, either clinical, public health or non clinical (commercial). As part of the approval process, applicants are required to agree to all CPQ operating requirements.

Application(s) are reviewed by the CPQ Planning Council (PC)*

* The PC has membership expertise in clinical and space planning, professional and facility licensing for the range of healthcare facilities and commercial organizations setting up as businesses in DHCC.

The Complementary and Alternative Medicine Council provides recommendations for licensing CAM HCOs and HCPs as well as for other CAM related regulatory functions including Pre-operating Assessment and the CAM Comprehensive Quality Survey. The Council also oversees the implementation of CAM Codes in DHCC clinics ensuring clinical audit and validation.

THelICenSInGdePArTmenT

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Approved applicants with completed lease or purchasing agreements with DHCC can now submit for review their proposed facility design and layouts in compliance with CPQ design guidelines, and for healthcare facilities as a minimum the American Institute of Architects (AIA) Guidelines for the Design and Construction of Healthcare Facilities.

In addition, medical equipment selection must comply with applicable FDA, CE or ICE standards for the class of equipment. A fit-out or building permit* will be issued’ following the design review process.

*Subject to TECOM Zoning Authority Requirements

At the completion of a project, CPQ will undertake a pre-operating assessment of the Facility (as built) and capacity to deliver the approved services in order to establish a readiness to operate. For clinical facilities the assessment includes operational requirements intended to ensure patient safety, enhance the quality of clinical care and advancing clinical excellence.

Assessed areas include:

• Confirmation of approved professionals• Facility conformance to approved design• Medical equipment installation and performance validation• Quality and patient safety• Clinical governance• Occupational Health Safety and Environment• Health informatics capabilities

A specific, but reduced level of inspection is undertaken for public health and non-clinical facility categories.

With all major pre-operating assessment requirements met, the applicant is processed through the PC for approval and issuing of a clinical operating permit via the Licensing Board. Other facility categories are issued public health and non-clinical operating permits as applicable. All operating permits have a two-year duration before renewal.

Clinical operators are subject to regular CPQ post-operating surveys during the initial 18 months of operation to ensure adopted quality standards are adhered to and accreditation is achieved. Public health and non-clinical operator inspections are also conducted by CPQ and other authorities having jurisdiction.

THelICenSInGdePArTmenT

PrOfeSSIOnAllICenSInGDHCC’s Professional Licensing Department (PLD) reviews each license application for HCPs before sending it to DHCC’s Licensing Board.

A vital component of CPQ’s professional licensing process is credentialing – the assessment of a healthcare professional’s competency and eligibility for licensure. “Credentialing” has been specifically defined under DHCC law as “the process undertaken by the DHCC Licensing Board to ensure that a healthcare professional meets the standards to enable that person to be licensed in DHCC. Credentialing involves the systematic process of assessing and confirming the qualifications and credentials of a healthcare practitioner.

The process includes : 1) collecting information about the practitioner; information that is not readily accessible to the public; 2) verifying the authenticity and accuracy of key certificates and credentials from the source of their issuance through a process called Primary Source Verification (PSV); 3) assessing and interpreting the information; and 4)

making decisions about the qualifications of a practitioner to provide specific services both as a basis for licensure and in specific healthcare facilities. The Professional Licensing continues to implement and manage its credentialing and Primary Source Verification (PSV) processes on behalf of the DHCC Licensing Board efficiently and effectively.

Through ensuring excellent levels of communication with academic institutions and regulatory authorities around the world, the Professional Licensing has established itself as a world class credentialing brand. This has undoubtedly contributed to its ability to routinely complete PSV activities for each license application within the target timeframe.

DHCC’s Licensing Board is an independent body that is the final license-granting authority in DHCC. The Board is appointed by DHCC’s Board of Directors and has ultimate responsibility for the licensing and credentialing of HCPs and HCOs within DHCC. Furthermore, all policy decisions regarding the licensing process and criteria are approved by the Board. DHCC’s Licensing Board has become a member of the International Association of Medical Regulatory Authorities (IAMRA), making it the first medical regulatory authority in the Middle East to join the organization. DHCC’s Licensing Board is composed of prominent healthcare experts from local and international arenas.

The Complementary & Alternative Medicine (CAM) Council was established to regulate the practice of CAM in DHCC. The CAM Council is mandated to approve CAM professionals and facilities under specific rules and regulations that are in line with DHCC’s high-quality standards of care. The scope for CAM includes, but is not limited to, homeopathy, osteopathy, chiropractic, tai chi and yoga, among others. All CAM applications must pass the CAM Council to obtain initial approval for professional and facility applications.

Academic & Research LicensingThe key objective of Academic & Research Licensing is to regulate all academic and research activities taking place in DHCC in collaboration with other concerned authorities in the UAE.

CPQ through the Academic & Research Licensing governance framework is demonstrating its commitment to best practices in providing education, training and knowledge sharing programmes.

QuAlITyImPrOvemenT

The mission of DHCC’s Healthcare Quality Department is to identify, evaluate and implement best practices to improve patient safety and quality of care.The focus of quality improvement is patient-centered healthcare. Responsibilities of the Quality Improvement Department include the following:

• Ensuring that DHCC’s clinical standards are implemented by healthcare organizations

• Ensuring that healthcare organizations have the appropriate mechanisms for monitoring, evaluating and improving the quality of healthcare provided

• Assisting HCOs in DHCC to improve when quality expectations are not being met

• Assuring that quality of care and patient safety in DHCC are sustained over time

DHCC’s commitment to the highest quality of healthcare and patient safety is the foundation for a globally acknowledged centre of excellence in healthcare.

Hospital Accreditation Surveys

Outpatient Clinic Quality Standards

Accreditation is a process in which an entity, separate and distinct from the HCO, usually non-governmental, assesses the HCO to determine if it meets a set of standards and requirementsdesigned to improve the quality of care. Accreditation provides a visible commitment by an HCO to improve the quality of patient care, ensure a safe environment and continually work to reduce risks to patients and staff. Accreditation has gained worldwide attention as an effective quality evaluation and management tool. The Joint Commission International (JCI) was appointed by DHCC to accredit hospitals operating within DHCC. This selection demonstrates the commitment by DHCC to provide safe and high-quality care. All hospitals operating within DHCC are required to obtain accreditation by JCI within 2 years and then every 3 years afterwards.

To ensure high-quality care and patient safety, each HCO in DHCC is required to commit to DHCC’s clinical quality standards that are grouped into the following 10 sections:1. Environment of Care2. Leadership and Governance3. Staff Qualifications, Education and Training4. Access and Continuum of Care5. Patient Assessment and Care6. Patient and Family Rights7. Patient and Family Education8. Performance Measurement 9. Infection Prevention and Control10. Health Information Management

Outpatient Clinic Assessment Surveys

Communicable Diseases Reporting

Performance measurement The assessment survey process serves as a tool for improvement and re-licensure. The assessment process ensures that HCOs meet core healthcare quality standards. Assessment surveys are conducted by CPQ at 6 months of operation and again at 18 months of operation. The surveys are repeated every 2 years for the duration of the facility’s operation within DHCC.

The surveillance of infectious diseases effectively prevents the spread of suspected or confirmed diseases into the greater community. The collection of International Classification of Disease (ICD) coding, which provides statistical information locally, nationally, and internationally, is important in the management, control, analysis and prevention of disease cases and related outbreaks.

It is necessary and important to take immediate measures to ensure disease prevention and disease communicability through early detection reporting within DHCC facilities. All healthcare facilities within DHCC must comply with the disease notification and reporting process. Performance MeasurementQuality can be defined, measured and improved. Performance measurement is a strategy to improve quality and patient safety. HCPs “manage what they measure,” therefore, each HCO in DHCC must participate in performance measurement and performance improvement activities.

Performance measurement of HCOs is achieved through the following mechanisms:

• Monitoring compliance to quality standards• Monitoring communicable diseases• Monitoring sentinel events• Developing and implementing clinical indicators• Conducting patient satisfaction surveys

Performance ImprovementPerformance improvement of HCOs is achieved through the following mechanisms:

• Developing and conducting educational activities and workshops to support patient safety initiatives and ensure compliance to challenging standards

• Providing HCOs with survey recommendations and following up with implementation of the recommendations

• Analyzing and trending data from communicable diseases reporting

• Providing assistance with root cause analysis and action plans when required, for example, when sentinel events are reported

• Analyzing and trending data from clinical indicators reporting• Analyzing patient satisfaction surveys and providing

recommendations based on the findings

QuAlITyImPrOvemenT

HeAlTHCAreInfOrmATICSdePArTmenTCPQ places a strategic emphasis on the use of healthcare data. Information technology enables the integration, storage, reporting and analysis of healthcare data submitted to DHCC by the HCOs. Healthcare data from more than 600,000 patient visits have been collected to assist CPQ with its monitoring, planning and regulating activities.

To monitor the quality and planning of DHCC HCOs, CPQ mandates that HCOs submit electronically data elements on their patient activity, on a regular basis as stated in DHCC Minimum Data Requirement Rule. HCO data will be collected and reported through the Healthcare Information Reporting and Analysis System (HIRAS), a state-of-the-art HIT system developed and maintained by DHCC. CPQ’s Healthcare Informatics Department will coordinate the process of collecting data with DHCC HCOs. Further, CPQ requires HCOs to implement IT systems (Electronic Medical Record “EMR” or Physician Practice Management System “PPMS”) to collect, store, maintain and retrieve their patient information.

Minimum Data RequirementCollection of Healthcare Data

The HCO IT system must be integrated with HIRAS through any of the following methods:

1. HL 7: if the HCO IT system is HL 7 compatible, HCO can submit the required data through HL7 messaging protocol

2. Application Programming Interface (API): if the HCO IT system is not HL7 compatible, HCOs can incorporate the DCF-API developed by DHCC in their application to send required data to HIRAS.

The PPMS or EMR will serve the HCOs within DHCC, whereas the HIRAS will be used by CPQ for analytics and reporting related to healthcare planning and quality.

In addition, to quality and planning purposes, HIRAS will be used as a platform for DHCC Electronic Health Record and Integrated Healthcare Network (IHN).

Each Licensed HCO in DHCC is required to submit all mandatory data elements as listed in DHCC Minimum Data Requirement Rule to CPQ to monitor quality and planning. CPQ may add or delete data elements listed in the rule, based on the requirement. CPQ Healthcare Informatics Department will publish DHCC Healthcare Data Dictionary, which will include description of each data element required.

Medical Coding Training & Education

Reporting to Government Health Authorities

Patient Data Confidentiality

Data Validity Audit

HID devotes considerable time and energy to educating HCO staff on the CPQ clinical coding standards and methodologies. Monthly General Coding training and Specialty Coding training programmes are offered free of charge to all HCOs. The following Coding Standards training is provided to HCOs:

• The World Health Organization’s ICD-10 for the International classification of diseases

• The American Medical Association’s CPT-4 for Current Procedural terminology coding

• Alternative Link Organization (ABC) coding for Complementary and Alternative Medicine coding

• The American Dental Association’s CDT for Dental procedural coding

All licensed HCOs in DHCC are required to submit patient statistics to Dubai Health Authority (DHA). However, HCOs need not submit data to different regulatory bodies other than CPQ, by integrating with HIRAS.

CPQ Quality Improvement Department has implemented a manual process for reporting infectious and communicable diseases to DHA. The reporting process will be automated once integration of DHA system with HIRAS is completed.

HIRAS hosts and manages patient health information provided by the HCOs within DHCC, and guarantees the confidentiality of the information. DHCC has developed stringent policies and procedures to protect the confidentiality of patient health information. Whenever possible, the data stored in HIRAS will be used without patient identifiers.

To maintain the quality of data received from HCO, HID conducts annual data validity audit site visits free of charge. These visits help in the improvement of data quality reported by the HCO and to monitor international quality standard in patient care.

HeAlTHCAre InfOrmATICS dePArTmenT

CuSTOmer PrOTeCTIOn unITThe Customer Protection Unit (CPU) at CPQ manages the DHCC customers’ complaints, and feedback. The purpose of this unit is to improve the overall safety and quality of healthcare in DHCC while maintaining the highest levels of customer satisfaction. CPU is the lifeline to DHCC’s overall customer satisfaction.

CPU is responsible for collecting information concerning the quality of healthcare provided by the operators, and professionals. CPU undertakes a proactive method that aims to put the customers’ wellbeing in their own hands and allows DHCC to work closely with its patients in delivering quality care.

Various information concerning access, communication, costs, decision-making, quality of clinical care, rights, respect and dignity as well as professional conduct, non-compliance, and corporate services are collected, through the feedback and complaints management system, to improve the quality of services provided.

To meet CPQ quality and ISO 10002:2004 standards pertaining to complaints management, the Customer Protection Unit (CPU) ensures a systematic approach for receiving, analyzing and responding to customers’ complaints and feedback.

In addition to complaints management, CPU undertakes the full responsibility of monitoring and enforcing strict regulations and standards. This is to monitor compliance to DHCC Governing Regulations and Quality Standards, and to apply a specific enforcement system.

Role of PSU•DevelopmentandimplementationofpharmacyandpharmaceuticalsrulesandregulationinDHCC

•Monitoringandinspectionofallpharmacies,pharmaceuticalestablishments,clinicsandhospitalswithregardtohandlingmedicationandotherpharmaceuticaloperationissuestoensurecompliancewithregulationandenhancethestandardsofpharmacypracticeinDHCC

PHArmACy ServICeSunIT

• Education through the provision of pharmacy and pharmaceutical-related education sessions which include but are not limited to operational orientation sessions, pharmaceutical policies communication and other pharmaceutical education programmes

• PSU plays a vital role in enhancing medication management in close collaboration with DHCC pharmacies and other healthcare operators to ensure safe medication handling and to improve patient care

PSU also coordinates with the MOH on a range of pharmaceutical services including:

• Processing MOH registration for pharmacies and pharmaceutical establishments within DHCC

• Approvals for new services/ therapy lines • Acquiring Narcotics, controlled and semi controlled

medications, and the required stationery for prescribing and using restricted medication

• Processing special import permits for needed medications.

Pharmacy Services Unit The Pharmacy Services Unit (PSU) is committed to enhancing pharmacy practice and providing an expert professional advisory service on pharmacy and pharmaceuticals-related issues.

PSU also provides liaison with the Ministry of Health (MOH) and other authorities to ensure the smooth collaboration and day-to-day follow up on issues relating to pharmaceuticals and new therapies.

PSU offers assistance to DHCC clients in all areas relevant to pharmacy, new therapy, drug information, medication management and pharmaceutical products.

For more specific information regarding CPQ, please contact:P.O. Box: 66566, Dubai, UAE, Tel: 800 HEALTH (432584), Fax: +971 4 362 4770,

Email: info@cpq.dhcc.ae