The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Division of Health Care Quality
99 Chauncy Street, 2nd Floor, Boston, MA 02111
617-753-8000

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN  AUERBACH
COMMISSIONER	

Circular Letter: DHCQ-09-06-510

TO: 		Hospital Chief Executive Officers 
Risk Managers 

FROM: 	Paul Dreyer, Ph.D. 
Bureau Director 
		
DATE: 	June 22, 2009

SUBJECT: 	Hospital Reporting of Serious Reportable Events (SREs)

This letter provides updated instructions for the reporting of serious incidents and Serious Reportable Events (SREs). This topic has been discussed previously in Circular Letters DHCQ 08-07-496, DHCQ 08-06-489 and DHCQ 07-12-478.  These updated instructions address recent amendments to 105 CMR 130.000, Hospital Licensure.  The amendments implement provisions of chapter 305 of the Acts of 2008, An Act to Promote Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care, signed into law by Governor Patrick on August 10, 2008.   

Hospitals are required to report SREs to the Department and are now prohibited from charging or seeking reimbursement for SRE-related services.  A revised reporting process for SREs has been developed to implement the new provisions.  These updated instructions should be used for cases reported on or after June 12, 2009.

There are now two components of the reports required for SREs: one within seven calendar days of discovery of the occurrence of the SRE (pages 1-5 of the form), and an update within 30 calendar days of the initial report (page 6 of the form).  As part of the revised form, hospitals must attest that they have provided copies of the report to patients or their representatives, as well as any relevant third party payer.  For both the 7 and 30 day reports, the payers should receive the same report as the one provided to the Department.  Patients must receive a copy of the thirty day report and must be offered a copy of the seven day report, but the written communication required at seven days can be a summary of the verbal discussion between the provider and patient.  Line by line instructions are provided as an attachment to the revised form.  Hospitals are required to complete all of the components of the form, regardless of whether they will be seeking reimbursement for the services provided.

If a hospital discovers an SRE that occurred at a different hospital or freestanding ambulatory surgery center (ASC) than the hospital that discovers the SRE, the discovering hospital should file pages 1-4 of the form and indicate the hospital or ASC where the SRE occurred, if known.  Please contact the Department in this case.

Any hospital that is having trouble meeting the reporting deadlines on a particular case should call the Department immediately to discuss specific concerns.   Any appeals related to payment or non-payment of an SRE will be handled through a provider’s claims process and not through the Department.

Old forms will not be accepted as of the date of the issuance of this letter.  Pages 1-3 of this updated form are to be used for the reporting of serious events that are not SREs, using the Department’s current process.

Please contact Elizabeth Daake at Elizabeth.Daake@state.ma.us or (617) 753-7016 if you have any questions regarding the regulations or policies.  If you have questions about the reporting of a specific incident, please contact Sean Dore or Lillian Jette at (617) 753-8150.

Attachment:

1.	Hospital Fax Reporting Form with Directions