Specialised Services
Discussion Draft
Health Authority Abu Dhabi
Reliable Excellence in Healthcare
Specialised services summary
• HAAD defines specialised services where there is evidence that
concentrating clinical expertise improves outcomes substantively.
• HAAD will restrict provision of specialised services to facilities it issues a
certificate of need to.
• All payers must fully and only reimburse certificated providers at a HAADdefined base rate for such specialised services, which are specified at the
DRG-level.
• Current specialised services are
– Major Burns at Mafraq
– Tertiary Cancer Surgery at Tawam
– Cardiothoracic Surgery at SKMC
– Neurosurgery at SKMC
– Infant surgery at SKMC
– Solid Organ Transplantation programmes at SKMC
– Major Trauma research centre at SKMC
– Major Trauma centre at Al Ain
1
Specialised services
• Certification and audit
• DRG specification for reimbursement
• Service specification
• Clinical rationale and evidence
2
Certification and audit
• HAAD issues a certificate of need for 5 years (renewable) based on a successful initial
audit. The certificate entitles facility staff to provide the specialised service at other
licensed facilities, as appropriate.
• Operators submit to HAAD an activity-based budget for the subsequent Calendar year
by April 30, net of all other payments. For any transition period to reach the full service
specification, the Operator will also submit service specification milestones to be met by
the beginning of each Calendar year.
• HAAD schedules an annual audit of the service against the service specification.
• HAAD pursues an escalation procedure in case of a failed audit
1. Issue a deficiency letter with 90 days to correct deficiencies identified and re-audit
the service after the 90 day period has elapsed.
If the re-audit fails:
2. Issue an enforcement notice which may add, impose, vary or remove conditions
with a further 120 days (maximum) to comply. Re-audit the service after the 120
day period has elapsed
If the second re-audit fails:
3. Consider suspension, removal and replacement of the managing operator
responsible for service delivery of the specialised service.
3
Specialised services
• Certification and audit
• DRG specification for reimbursement
• Service specification
• Clinical rationale and evidence
4
DRG specification for reimbursement
• All DRGs for surgery on infants <1yr of age
• All surgical DRGs with principal diagnosis malignant cancer
• The following specific DRGs:
DRG
051011
051012
051013
051021
051022
051023
051031
051032
051033
051041
051042
051043
051051
051052
051053
051071
051072
051073
051061
051062
051063
111011
111012
111013
DRG description
IP HEART &/OR LUNG TRANSPLANTATION
IP HEART &/OR LUNG TRANSPLANTATION w/CC
IP HEART &/OR LUNG TRANSPLANTATION w/MCC
IP CARDIAC VALVE PROCEDURES WITH CARDIAC CATHETERIZATION
IP CARDIAC VALVE PROCEDURES WITH CARDIAC CATHETERIZATION w/CC
IP CARDIAC VALVE PROCEDURES WITH CARDIAC CATHETERIZATION w/MCC
IP COMPLEX CARDIOTHORACIC REPAIR OF HEART ANOMALY
IP COMPLEX CARDIOTHORACIC REPAIR OF HEART ANOMALY w/CC
IP COMPLEX CARDIOTHORACIC REPAIR OF HEART ANOMALY w/MCC
IP CARDIAC VALVE PROCEDURES WITHOUT CARDIAC CATHETERIZATION
IP CARDIAC VALVE PROCEDURES WITHOUT CARDIAC CATHETERIZATION w/CC
IP CARDIAC VALVE PROCEDURES WITHOUT CARDIAC CATHETERIZATION w/MCC
IP CORONARY BYPASS WITH CARDIAC CATHETERIZATION
IP CORONARY BYPASS WITH CARDIAC CATHETERIZATION w/CC
IP CORONARY BYPASS WITH CARDIAC CATHETERIZATION w/MCC
IP CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION
IP CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION w/CC
IP CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION w/MCC
IP OTHER CARDIOTHORACIC PROCEDURES
IP OTHER CARDIOTHORACIC PROCEDURES w/CC
IP OTHER CARDIOTHORACIC PROCEDURES w/MCC
IP KIDNEY TRANSPLANTATION
IP KIDNEY TRANSPLANTATION w/CC
IP KIDNEY TRANSPLANTATION w/MCC
Specialised service
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Cardio-thoracic surgery
Transplantation
Transplantation
Transplantation
DRG
011011
011012
011013
011101
011102
011103
011111
011112
011113
011121
011122
011123
011201
011202
011203
011301
011302
011303
091201
091202
091203
071011
071012
071013
DRG description
IP INTRACRANIAL VASCULAR PROCEDURES
IP INTRACRANIAL VASCULAR PROCEDURES w/CC
IP INTRACRANIAL VASCULAR PROCEDURES w/MCC
IP CRANIOTOMY
IP CRANIOTOMY w/CC
IP CRANIOTOMY w/MCC
IP VENTRICULAR SHUNT PROCEDURES
IP VENTRICULAR SHUNT PROCEDURES w/CC
IP VENTRICULAR SHUNT PROCEDURES w/MCC
IP EXTRACRANIAL VASCULAR PROCEDURES
IP EXTRACRANIAL VASCULAR PROCEDURES w/CC
IP EXTRACRANIAL VASCULAR PROCEDURES w/MCC
IP CRANIAL & PERIPHERAL NERVE PROCEDURES
IP CRANIAL & PERIPHERAL NERVE PROCEDURES w/CC
IP CRANIAL & PERIPHERAL NERVE PROCEDURES w/MCC
IP SPINE PROCEDURES
IP SPINE PROCEDURES w/CC
IP SPINE PROCEDURES w/MCC
IP SKIN GRAFT WITH BURNS
IP SKIN GRAFT WITH BURNS w/CC
IP SKIN GRAFT WITH BURNS w/MCC
IP LIVER TRANSPLANTATION
IP LIVER TRANSPLANTATION w/CC
IP LIVER TRANSPLANTATION w/MCC
Specialised service
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Burns
Burns
Burns
Transplantation
Transplantation
Transplantation
Source: International Refined Diagnosis Related Groups (IR-DRG v2.2) ICD-9-CM/CPT Definitions Manual, Volume II; www.shafafiya.org
5
Specialised services
• Certification and audit
• DRG specification for reimbursement
• Service specification
• Clinical rationale and evidence
6
Major burn care
• A specialised major burn care centre provides the highest level of clinical care to patients
with burn injury. It consists of:
• Inpatient/outpatient service including:
– 24/7 cover of qualified burn surgeons, anesthesiologists and support staff
– Dedicated burns ward with temperature-controlled cubicles
– Burns ICU beds
– Dedicated burns theatre
– Psychology support
– Clinical leadership of burn care network
– Telemedicine links with receiving hospitals
• All other hospitals and ambulances ‘receivers’: stabilisation measures in place (protocols
established, local staff trained, kit deployed)
• Effective ‘retrieval’ service from receiver to centre of excellence (protocols established,
local staff trained, communications infrastructure in place, financing in place)
• The ‘retrieval’ service may draw on or be used by other services for efficiency purposes,
e.g., Trauma, ICU.
Sources: New South Wales Burn Injury Service Model of Care NSW Department of Health 2004; New South Wales Burn Injury Service Burn Transfer Guidelines NSW Department of Health 2004
Cardiothoracic surgery
• A specialised cardiothoracic surgery service provides the highest level of surgical care to patients with
heart and lung disorders
• A specialised cardiothoracic surgery service consists of:
– A fully staffed and equipped cardiac surgical department that includes a consultant led surgical team
of qualified adult and pediatric cardiothoracic surgeons available 24/7 that provide cardiothoracic
surgery to a minimum required annual volume of 500 patients
– Dedicated 24/7 cardiac theatres and operating lists
– A full range of cardiology physicians and cardiac trained anesthesiologists available 24 hours a day
– Prompt, on site availability of other supporting specialties including:
Clinical Perfusion
CCU, ICU, PICU
Nephrology
Interventional cardiac catheterisation
• A specialised cardiothoracic surgery service
– Achieves average mortality for coronary surgery of <1.8% (30 day post operative)
– Achieves average mortality for congenital heart surgery of <4% (30 day post operative)
– Provides clinical leadership of the region’s cardiothoracic services
– Provides outreach services for outpatient care across the emirate as agreed by HAAD
– Runs a Research programme attracting a minimum AED 350,000 funding per annum
Source The European Association for Cardio-Thoracic Surgery Adult Cardiac surgery database report 2010. Congenital mortality: Mortality rates after
surgery for congenital heart defects in children and surgeons' performance. Institute of Child Health, London
8
Major Trauma research center*
A Major trauma research center* provides the highest level of surgical care to trauma patients. It
consists of:
• A fully staffed and equipped accident and emergency department that includes a consultant
led resuscitative trauma team, a surgical residency programme, dedicated trauma theatres
and operating lists
• A wide range of general and specialist surgeons, emergency physicians and
anesthesiologists available 24 hours a day and admits a minimum required annual volume
of 500 surgical DRGs or above of the most severely injured (DRG severity level 2 or 3)
patients
• 24-hour on site, consultant led, availability of all major including as a minimum:
orthopedic surgery
plastic surgery
interventional radiology
ICU, PICU
neurosurgery
oral and maxillofacial surgery
cardiothoracic & vascular surgery
internal medicine
• Facility to provide clinical leadership of the regions Trauma services and provide:
improved survival rates of admitted trauma patients year-on-year
an educational programme delivering 500 CME credits annually,
a research programme attracting funding of at least AED 350,000 per Year
* Based on American definition of ‘Level 1 Trauma center’
Sources: Royal College of Surgeons of England Provision of Trauma Care Policy Briefing 2007. American College of Surgeons – Committee on Trauma designation review. 1997
Major Trauma centre
• Works in collaboration with a Major Trauma research centre. It provides comprehensive trauma care
and supplements the clinical expertise of a Level I institution. It provides 24-hour availability of all
essential specialties, personnel, and equipment. It consists of:
– A fully staffed and equipped accident and emergency department that includes a consultant led
resuscitative trauma team, dedicated trauma theatres and operating lists
– A range of specialist surgeons
– General surgeons, emergency physicians and anesthesiologists available 24 hours a day
– Admits a minimum required annual volume of 250 surgical DRGs or above of the most severely
injured (DRG severity level 2 or 3) patients
– 24-hour on site, consultant led, availability of major specialties including as a minimum:
orthopedic surgery
plastic surgery
oral
and maxillofacial surgery
interventional radiology
ICU
internal medicine
• Is not required to have an ongoing program of research but is required to collaborate closely with the
Major Trauma research centre in research, service delivery and major incident management
• Improves the survival rate of admitted trauma patients year-on-year
* Based on American definition of ‘Level 2 Trauma center’
Source Royal College of Surgeons of England Provision of Trauma Care Policy Briefing 2007 . American College of Surgeons – Committee on Trauma designation review. 1997
Neurosurgery
A specialised neurosurgery centre provides the highest level of surgical care to patients with
disorders of the central nervous system. It consists of:
• A fully staffed and equipped neurosurgical department that includes a consultant led surgical
team of qualified adult and pediatric neurosurgeons available 24/7 that provide neurosurgery
to a minimum required annual volume of 250 patients
• Dedicated neurosurgery theatres and operating lists
• Anesthesiologists trained in the management of Adult and paediatric neurosurgery patients
available 24 hours a day
• Prompt, on site availability of other supporting specialties such as:
Maxillofacial surgery ICU, PICU
ENT
24/7 access to Interventional radiology, CT & MRI
Neuro-psychology
Occupational therapy
• Facility to provide clinical leadership of the regions neuroscience services and provide:
–
–
–
Average mortality for Neurosurgery surgery of <4.9% (30 day post operative)
Outreach services for outpatient care across the emirate as agreed by HAAD
Research programme attracting a minimum AED 350,000 funding per annum
Sources : UK specialised services national definitions set (3rd edition ) 2010. Mortality rate: University HealthSystem Consortium, Mortality statistics.
11
Infant surgery
A specialised Infant surgery service for patients <1 years of age consists of:
• 1 Single, designated center-of-excellence inpatient/outpatient service equipped and staffed to
deliver all aspects of infant and neonatal surgery
• 24/7 cover of paediatric and neonatal surgeons, paediatricians and anesthesiologists qualified
and experienced in the care of neonates and infants
• Dedicated paediatric operating lists, dedicated PICU, HDU and paediatric ward facilities
• Full range of diagnostic and supporting specialties including:
MRI, CT
PICU, HDU, access to NICU service
interventional radiology
play therapy
Facility to provide clinical leadership of the regions infant surgical services and provide:
– Average perioperative (7day) mortality for surgery on children <1 year old of <0.06%
(excludes cardiac, neurosurgery and neonatal specialties)
– Outreach services for outpatient care across the emirate as agreed by HAAD
– Research programme attracting a minimum AED 350,000 funding per annum
• For surgical emergencies on infants under 1 years of age all other hospitals and ambulances
‘Receive and refer’: Stabilisation measures in place (protocols established, local staff trained)
Sources: Camplin ES, Devlin HB, Lunn JN. Report of the national confidential enquiry into perioperative deaths (NCEPOD) London, 1990. Atwell JD, Spargo PM The provision of safe surgery in children
Southampton, UK 1992.. Mortality : Morita K et al. Perioperative mortality & morbidity in the year 2000 in 520 certified training hospitals., Okayama, Japan 2002.
Cancer surgery
A specialised cancer surgery centre provides the highest level of surgical care to patients
with cancer. It consists of:
• A fully staffed and equipped surgical department that includes a consultant led
surgical team of a minimum of 3 qualified adult and pediatric general surgeons
available 24/7 that provide complex cancer surgery including thoracic cancers to a
required annual volume of 200 or more patients
• Dedicated theatres and operating lists
• Prompt, on-site availability of other supporting specialties including:
ICU, PICU
radiation oncology
Interventional radiology
palliative care
Histopathology
clinical psychology
• Facility to provide clinical leadership of the regions cancer services including
teaching, research, quality improvement and program advancement
The specialised centre is required to develop systems that enable the benchmarking of
outcome performance against international norms
Sources: UK Specialised Services National Definitions Set (3rd Edition)2010. Survival rates: Cancer Research/ cancer survival stats. UK 2010.
13
Solid organ transplants
• A specialised organ transplant centre provides the highest level of care to patients who undergo
organ transplantation. It consists of a range of transplant services including but not limited to
Kidney, Liver and Pancreas transplants
• Individual service specifications will need to be developed for each type of transplant surgery
however as a minimum they should consist of:
• A fully staffed and equipped transplantation department that includes a consultant led
surgical team with a minimum of 3 qualified transplantation surgeons available 24/7
• Dedicated theatres and operating lists
• Prompt, on site, availability of other supporting specialties such as:
Cardiology, Haematology
ICU, PICU, Psychology
Nephrology
Interventional radiology
• Facility to provide clinical leadership of the regions organ transplant services including
delivery of:
– an educational programme delivering 250 CME credits annually,
– a research programme attracting funding of at least AED 350,000 per Year
– A one year post transplantation survival rate of >96% for patients undergoing kidney
transplants from living donors
– One year survival rates for future transplant surgery equal to or better than the benchmarks
provided by The U.S. Organ Procurement and Transplantation Network and the Scientific
Registry of Transplant Recipients
Sources : UK specialised services national definitions set (3rd edition) 2010. Mortality: Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry
of Transplant Recipients: Transplant Data 1992–2001. Rockville, MD: HHS/HRSA/OSP/DOT, 2003.
14
Specialised services
• Certification and audit
• DRG specification for reimbursement
• Service specification
• Clinical rationale and evidence
15
Major burn care
Burn care is the field of medicine involved in the treatment of burn injuries
from the most minor, dealt with in the community, to the most severe and
devastating. Burn injuries are highly variable and individual injuries affecting all
ages and social groups
• In general terms the definition of a major burn is based on the size and
anatomical site of the injury, the depth of skin injury, and the presence of
co-existing conditions
• International experience shows that outcomes are improved when the
treatment of major and more complex burns is centralised to a single or
fewer sites
• The significant expansion of Oil & Gas activities in Al Gharbia is associated
with substantial burn risks
• This is consistent with it being designated as a ‘specialised service’, for
which HAAD will only license one or two facilities in the Emirate
Source: UK Specialised Services National Definitions Set (3rd Edition) 2010.
16
Cardiothoracic surgery
• Cardiothoracic surgery is the field of medicine involved in surgical treatment
of diseases affecting organs inside the thorax (the chest)—generally
treatment of conditions of the heart (heart disease) and lungs (lung disease)
• International experience shows that cardiothoracic surgery centers that
carry out a higher numbers of surgical procedures perform better, as
surgeons and support staff become more experienced/specialized.
• The number of cases presenting each year in Abu Dhabi does not warrant
more than a single centre for Cardiothoracic surgery
• HAAD has defined Cardiothoracic surgery as a specialized service with a
maximum of 1 unit to be designated
Source: UK Specialised Services National Definitions Set (3rd Edition) 2010.
17
Trauma service
• Trauma can be defined as physical injury caused by events such as road traffic
accidents, falls, explosions etc. Trauma is the second highest cause of death in the
emirate
• The region requires a network of hospitals and ambulance services geared to treat
trauma patients of varying complexities
• Level I trauma centre provides the highest level of surgical care to trauma patients. It
is supported by Level 2 and 3 trauma units that treat less complex trauma patients
• Evidence from the United States shows that positive outcome for major trauma
patients depends on them being delivered to a hospital that has the appropriate
range of specialist resources to treat multiple injuries. Being treated at a Level 1
Trauma Centre increases a seriously injured patient’s chances of survival by an
estimated 20 to 25 percent
• Major trauma patients are 1.5 to 5 times more likely to die than patients transported
directly to major trauma centers
• HAAD has defined Level 1 trauma as a specialised service with a maximum of 2 units
to be designated
Sources: HAAD statistical analysis, Royal College of Surgeons of England Provision of Trauma Care Policy Briefing 2007, American College of Surgeons – Committee on Trauma designation review.
1997
18
Neurosurgery
Neurosurgery is the field of medicine involved in surgical treatment of diseases or
conditions of the central nervous system (CNS) and spine. This includes six general
categories of neurosurgical diseases:
• cerebrovascular (hemorrhage and aneurysms);
• traumatic head injury (THI)(traumatic injury caused by accident);
• degeneration diseases of the spine;
• tumors in the CNS;
• functional neurosurgery and neurosurgical management of the CNS.
• surgery for congenital abnormalities;
• International experience shows that neurosurgery centers that carry out a higher
numbers of surgical procedures perform better, as surgeons and support staff
become more experienced/specialized.
• The number of cases presenting each year in Abu Dhabi does not warrant more
than a single centre for neurosurgery
Source : UK specialised services national definitions set (3rd edition) 2010.
19
Infant surgery
• infant surgery is the field of medicine involved in surgical treatment of diseases
affecting children
• Several large studies have confirmed that the incidence of perioperative anesthetic
and surgical complications is much higher in neonates and infants than in older
children
• International experience shows that mortality and morbidity for surgery on very
young children can be dramatically reduced by ensuring all surgery on children <1yr
of age is carried out in a specialised infant surgery centre
• The number of cases presenting each year in Abu Dhabi does not warrant more
than a single centre for surgery on children <1yr
• HAAD has defined infant surgery under 1 year of age as a specialised service
Sources: Camplin ES, Devlin HB, Lunn JN. Report of the national confidential enquiry into perioperative deaths (NCEPOD) London, 1990. Atwell JD, Spargo PM The provision of safe surgery in
children Southampton, UK 1992
20
Cancer surgery
• Tertiary cancer surgery — is the field of medicine involving major surgery
to repair or remove parts of the body to treat cancer
• It remains as the foundation of cancer treatment. Cancer surgery may be
supplemented with other treatments, such as radiation, chemotherapy,
hormone therapy and biological therapy
• International experience shows that cancer surgery centres that carry out
a higher numbers of surgical procedures perform better, as surgeons and
support staff become more experienced/specialized
• The number of cases presenting each year in Abu Dhabi does not warrant
more than a single centre for tertiary cancer surgery
Source: UK Specialised Services National Definitions Set (3rd Edition) 2010.
21
Solid organ transplantation
Organ transplantation is the field of medicine involved in the surgical
transplantation of donor organs to treat irreversible failure of a recipient
organs including heart, lungs, liver, kidneys or other organs
• International experience shows that transplantation expertise should be
concentrated as outcomes from transplant surgery improve as surgical,
medical and support staff become more experienced/specialized
• The number of cases presenting each year in Abu Dhabi does not warrant
more than a single centre for organ transplantation; A review will be
undertaken to establish whether the volume and legal context support
even one centre at high quality
• HAAD has defined organ transplantation as a specialised service with a
maximum of 1 unit to be designated
Source : UK specialised services national definitions set (3rd edition ) 2010
22