243. Mass. Code Regs. 3.07. - Qualified Patient Care Assessment Program - Internal Audits and Internal Incident Reporting

All health care facilities and medical staff must have policies in place that calls for the reporting of a health care provider who is incompetent in his or her specialty or whose conduct has harmed patient safety.  The Patient Care Assessment Coordinator is responsible for following up on such reports.  The law also provides that when a health care provider has been the subject of disciplinary action by a health facility’s peer review committee, the recommendation must be forwarded to the executive committee and board of trustees of the facility.  

Health care facilities must make provisions for a Qualified Patient Care Assessment Program, which must include the following:

• The development and implementation of an incident based reporting system to the Patient Care Assessment Coordinator.  The system must also include training for health care providers and facility staff on the reporting system and quality assurance education;
• A review of discharged patient medical records to assess potential adverse patient occurrences that may not be evident;
• Develop other measures to reduce harm to patients;
• Central collection and investigation of patient complaints related to quality care.
• Provisions granting the Department of Public Health access to the information and records of the incident reports.

The Patient Care Assessment Coordinator must investigate the incident reports, and look for trends in the reports in order to identify corrective action that can be taken to improve patient safety.  The Coordinator must also provide a report to the facility’s governing body, and include recommendations for improving quality.  

All incident reports and recommendations must be maintained for at least three years.  The incident reports must be in writing and must include patient’s identifying information, a description of the incident, a list of all those involved in the incident, and the signature of the person completing the report.