The information on this page was last updated by Horty, Springer & Mattern on November 27, 2024.

MASSACHUSETTS

REPORTING REQUIREMENTS

Mass. Gen. Laws Ann. Ch. 111 §53B. Physician staff privileges; report of denial, restriction, revocation or failure to renew; liability of informant; annual disciplinary summary; penalty.

Any person licensed under section fifty-one shall report to the board of registration in medicine when the licensee denies, restricts, revokes, or fails to renew staff privileges, or accepts the resignation of, any physician registered with the board as qualified to practice medicine in the commonwealth for any reason related to the registrant’s competence to practice medicine or for any reason related to a complaint or allegation regarding any violation of law or regulation, or hospital, health care facility or professional medical association by-laws, whether or not the complaint or allegation specifically cites violation of a specific law, regulation or by-law. The report shall be filed within thirty days of the occurrence of the reportable action and include a statement detailing the nature and circumstances of the action, its date, and the reasons for it. Except as provided in section five of chapter one hundred twelve, all information contained in a report filed under this section shall be confidential, and the board may disclose it only if doing so is necessary to enable the board to use the information in a disciplinary proceeding against the registrant. Any person reporting information to the board under this section shall not be civilly liable for reporting such information if made and filed in good faith and without malice.

Any licensee subject to the reporting requirements set forth above shall file an annual disciplinary summary with the board of registration in medicine. The annual disciplinary summary shall be filed no later than January thirty-first for each previous calendar year. The annual disciplinary summary shall summarize the reports submitted for the previous calendar year. The annual disciplinary summary shall be sent by certified or registered mail, and it shall be under oath. If the licensee submitted no reports for the previous calendar year, then the annual disciplinary summary shall state that no reports were required. The board of registration in medicine shall promulgate such regulations as are necessary to carry out the intent of this section.

Upon a finding of violation of this section, the board of registration in medicine may assess a fine not in excess of ten thousand dollars.

112 §5E. Reports by physicians of settlements or arbitration awards; filing; penalty.

Any registered physician who does not possess professional liability insurance shall report to the board every settlement or arbitration award of a claim or action for damages for death or personal injury caused by negligence, error or omission in practice, or the unauthorized rendering of professional services by such physician. Such report shall be made within thirty days after any such settlement agreement has been reduced to writing thereto or thirty days after service of such arbitration award on the parties and signed by all the parties. Failure of the physician to comply with the provisions of this section is an offense punishable by a fine of not more than five hundred dollars. Knowing and intentional failure to comply with the provisions of this section, or conspiracy or collusion not to comply with the provisions of this section, or to hinder or impede any other person in such compliance is an offense punishable by a fine of not less than five thousand dollars nor more than fifty thousand dollars.

112 §5F. Reports of violations by health care providers; discrimination; liability of employers; exemption.

112 §5G. Communication with professional organizations or board; liability; counsel fees and costs.

(a) No person or health care provider who communicates with a peer review committee, administrative subcommittee, ethics committee or other similar committee of a health care provider, professional society of health care providers or entity which pays professional liability claims on behalf of any health care provider shall be liable in any cause of action arising out of the providing or receiving of such communication provided that such person or health care provider acts in good faith and with a reasonable belief that such communication was warranted in connection with or in furtherance of the functions of such committee.

(b) No person who reports information to the board as required in section five A through section five F inclusive, or as required in any other law or regulation shall be liable in any cause of action arising out of such report provided that such person acts in good faith and with a reasonable belief that such report was required. If such an action is instituted against a person who reports to the board as required in sections five A to five F, inclusive, and such action is determined by the court to be insubstantial, frivolous and not advanced in good faith, then such person defending such action may be awarded reasonable counsel fees and other costs and expenses incurred in defending against such action pursuant to section six F of chapter two hundred and thirty-one.

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Code of Mass. Regs. tit. 243, §3.02: Definitions

Board: The Board of Registration in Medicine, including, but not limited to, its Data Repository, Disciplinary Unit, Patient Care Assessment Unit, Legal Unit, Licensing Unit, and its agents and employees.

Disciplinary Action:  Please see 243 CMR 1.01(2).

Governing Body: the trustees, governing board or other persons responsible for establishing policy, maintaining quality patient care and providing for institutional management and planning at a health care facility.

Health Care Facility: any entity licensed pursuant to M.G.L. c. 111, s 51; any nursing home, within the meaning of M.G.L. c. 111, s 203(d); any state, county or municipal hospital; any entity maintaining more than one primary or episodic walk-in center; and any health maintenance organization within the meaning of M.G.L. c. 176G, s 1. The application of 243 CMR 3.00 to nursing homes and health maintenance organizations is limited as per 243 CMR 3.13 and 3.14.

Health Care Provider: As defined under M.G.L. c. 111, s 1, any doctor of medicine, osteopathy, or dental science, or a registered nurse licensed under the provisions of M.G.L. c. 112, or an intern, resident, fellow, or medical officer licensed under M.G.L. c. 112, a medical student, or a hospital, clinic or nursing home licensed under the provisions of M.G.L. c. 111 or a health maintenance organization within the meaning of M.G.L. c. 176G, s 1, and their licensed health professionals with employment, practice, association or privileges.

Licensee: a person holding any type of license issued pursuant to M.G.L. c. 112, ss 2 through 9B.

Medical Peer Review Committee: consistent with M.G.L. c. 111, s 1, a committee of a state or local professional society of health care providers or of a medical staff of a licensed hospital, nursing home, or other health care facility, provided the medical staff operates pursuant to written by-laws that have been approved by the governing board of the hospital, nursing home, or other health care facility, which committee has as its function the evaluation or improvement of the quality of health care rendered by providers of health care services, the determination whether health care services were performed in compliance with the applicable standards of care, determination whether the cost of health care services rendered was considered reasonable by the providers of health services in the area, the determination of whether a health care provider’s actions call into question such health care provider’s fitness to provide health care services, or the evaluation and assistance of health care providers impaired or allegedly impaired by reason of alcohol, drugs, physical disability, mental instability or otherwise.

Patient Care Assessment Committee: a medical peer review committee, as defined by 243 CMR 3.02, and consistent with M.G.L. c. 111, ss 1 and 204, that is created by the bylaws at the governing body level of a health care facility and which includes among its members not less than one governing body member, and other senior personnel essential to the quality of patient care, for example, higher level nursing administrators.

Patient Care Assessment Coordinator: a qualified physician or non-physician designated by a health care facility to implement and coordinate the facility’s Qualified Patient Care Assessment Program established pursuant to these regulations. To be qualified, the Patient Care Assessment Coordinator shall evidence by education, training or experience the ability to carry out the functions and activities of the Patient Care Assessment Program. In lieu of appointing a single Patient Care Assessment Coordinator, the governing body of a health care facility may designate a committee to carry out the Patient Care Assessment Coordinator’s functions as enumerated in 243 CMR 3.00. Thus, upon election of the health care facility’s governing body, all references herein to Patient Care Assessment Coordinator may include Patient Care Assessment Committee.

Qualified Patient Care Assessment Program: A health care facility’s rules, standards and procedures, adopted pursuant to the facility’s bylaws (unless otherwise required by statute), designed to establish effective programs in quality assurance, risk management, peer review, identification and prevention of substandard practice, and maximization of patient care assessment and thus minimization of loss, and which meet or exceed the rules, procedures and standards set forth in 243 CMR 3.00.  A Qualified Patient Care Assessment Program is a “risk management program” established by the Board of Registration in Medicine pursuant to M.G.L. c. 111, s 203(d) and recognized as a “risk management program” within the meaning of M.G.L. c. 112, s 5.

243 §1.01: Scope and Construction

(1)  Procedure Governed. 243 CMR 1.00 governs the disposition of matters relating to the practice of medicine by any person holding or having held a certificate of registration issued by the Board of Registration in Medicine under M.G.L. c. 112, §§ 2 through 9B, and the conduct of adjudicatory hearings by the Board.  243 CMR 1.00 is based on the principle of fundamental fairness to physicians and patients and shall be construed to secure a speedy and just disposition. The Board may issue standing orders consistent with 243 CMR 1.00 and 801 CMR 1.00: Standard Adjudicatory Rules of Practice and Procedure.

(2) Definitions.

Adjudicatory Hearing: a formal administrative hearing conducted pursuant to M.G.L. c. 30A.

Board: the Board of Registration in Medicine, including, but not limited to, its Data Repository/Data Management Unit, Disciplinary Unit, Patient Care Assessment Unit, Legal Unit, Licensing and Examining Unit, and its agents and employees.

Complaint: a communication filed with the Board which charges a licensee with misconduct. A Statutory Report is not a Complaint: See 243 CMR 1.03(14).

Disciplinary Action means an action adversely affecting a licensee which simultaneously meets the descriptions in 243 CMR 1.01 (2)(1) through (c), and which is limited as described in 243 CMR 1.01(2)(a) and (e).

(a) disciplinary action means an action of an entity including, but not limited to, a governmental authority, a health care facility, an employer, or a professional medical association (international, national, or local).

(b) A disciplinary action is:

1. formal or informal, or

2. oral or written.

3. An oral reprimand is not a Disciplinary Action. However, the fact that conduct resulted in an oral reprimand does not relieve any obligation to report under M.G.L. c. 112, § 5F.

(c) A disciplinary action includes any of the following actions or their substantial equivalents, whether voluntary or involuntary:

1. Revocation of a right or privilege.

2. Suspension of a right or privilege.

3. Censure.

4. Written reprimand or admonition.

5. Restriction of a right or privilege.

6. Non renewal of a right or privilege.

7. Fine.

8. Required performance of public service.

9. A course of education, training, counseling, or monitoring, only if such course arose out of the filing of a complaint or the filing of any other formal charges reflecting upon the licensee’s competence to practice medicine.

10. Denial of a right or privilege.

11. Resignation.

12. Leave of absence.

13. Withdrawal of an application.

14. Termination or non renewal of a contract with a licensee.

(d) The actions described in 243 CMR 1.01(2)(c)5., 6. and 10. through 14. are Disciplinary Actions only if they relate, directly or indirectly to:

1. the licensee’s competence to practice medicine, or

2. a complaint or allegation regarding any violation of law or regulation (including, but not limited to, the regulations of the Board (243 CMR)) or bylaws of a health care facility, medical staff, group practice, or professional medical association, whether or not the complaint or allegation specifically cites violation of a specific law or regulation.

(e) If based upon a failure to complete medical records in a timely fashion or failure to perform minor administrative functions, the action adversely affecting the licensee is not a Disciplinary Action for the purposes of mandatory reporting to the Board, provided that the adverse action does not relate directly or indirectly to:

1. the licensee’s competence to practice medicine, or

2. a complaint or allegation regarding any violation of law or a Board regulation, whether or not the complaint or allegation specifically cites violation of a specific law or regulation.

Informal: not subject to strict procedural or evidentiary rules.

Licensee: a person holding or having held any type of license issued pursuant to M.G.L. c. 112, §§2 through 9B.

Party: a respondent, associate prosecutor representing the disciplinary unit, or intervenor in an adjudicatory proceeding pursuant to 801 CMR 1.01(9).

Respondent: the licensee named in a Statement of Allegations.

Statement of Allegations: a paper served by the Board upon a licensee ordering the licensee to appear before the Board for an adjudicatory proceeding and show cause why the licensee should not be disciplined; a “Statement of Allegations” is an “Order to Show Cause” within the meaning of 801CMR1.01(6)(d).

243 §3.08: Qualified Patient Care Assessment Program–Major Incident Reporting to Board of Registration in Medicine

(1) Introduction. The requirement that health care facilities establish reporting and screening criteria for adverse events, as well as internal procedures for the review and analysis of incidents, is intended to promote quality assurance and peer review at each facility. In addition to allow the Board to meet its own statutory responsibility for the oversight of quality assurance programs, each health care facility must report Major Incidents (as defined below) to the Board.

(2) The following types of Major Incidents must be reported by the health care facility to the Board:

(a) Maternal deaths that are related to delivery.

(b) Death in the course of, or resulting from, elective ambulatory procedures.

(c) Any invasive diagnostic procedure or surgical intervention performed on the wrong organ, extremity or body part.

(d) All deaths or major or permanent impairments of bodily functions (other than those reported above) that are not ordinarily expected as a result of the patient’s condition on presentation.

The first three types of major incidents are specified outcomes that should be reported without regard to the underlying circumstances. The fourth type of major incident represents severe adverse outcomes that fall outside the realm of ordinarily expectable results, taking into account the nature of the underlying disease process and the recognized risks and benefits of appropriate medical responses to it. An event may be of this last type solely by virtue of its rarity as a natural outcome of the disease or intervention. Identification of an event as any one of the four types of major incidents, rare or not, does not necessarily indicate either that the outcome was preventable or that it resulted from substandard medical practices.

(3) Health care facilities shall file major incident reports with the Board on a quarterly basis. When reporting a major incident, health care facilities shall use the Board’s form prescribed for that purpose. For each major incident, the form will require the submission of certain information including but not limited to a description of the major incident, the results of the internal investigation and a description of the corrective measures taken by the health care facility. The reporting of the name(s) of the licensee(s) involved in the major incident initially will be optional. If the health care facility chooses to withhold the name(s) of the involved licensee(s), the Board may require additional information to enable it to evaluate the licensee’s background, skills and involvement in prior major incidents. If at any time during the course of its investigation, the Board requires the name(s) of the involved licensee(s) in order to assess the adequacy of the response of the health care facility’s PCA program to the major incident, the facility shall provide such name(s).

(4) If a health care facility is identified as deficient in the reporting of major incidents, the Board may request certain additional information from that facility consistent with its authority to request data under M.G.L. c. 111, s 203 and M.G.L. c. 112, ss 5 and 51.

(5) 243 CMR 3.08 does not relieve the health care facility of any other reporting obligation required under law or regulation, including but not limited to M.G.L. c. 111, §53B.

243 CMR §3.09 – Qualified Patient Care Assessment Program – Impaired Health Care Providers

 (1) The health care facility and medical staff bylaws must authorize a procedure for ongoing review and counseling of health care providers impaired by drugs or alcohol, or the health care facility must arrange for and monitor participation in other established review and counseling programs. The health care facility and medical staff bylaws must also authorize a procedure to ensure compliance with M.G.L. c. 112, § 5F, with specific regard to reporting impaired licensees to the Board.

(2) The Patient Care Assessment Coordinator must be kept apprised of any review and monitoring pursuant to 243 CMR 3.09(1).