To date, reports have only been accepted in a paper format. In order to improve efficiency and decrease the burden of regulatory reporting, the Board’s Quality and Patient Safety Committee will accept these required reports submitted electronically via the electronic platform designated by the Board. The Board’s Quality and Patient Safety Division will provide guidance documents to assist healthcare facilities with these changes.
Related Statutes:
M.G.L. c. 112, § 5.
M.G.L. c. 111, § 203(d).
M.G.L. c. 111, § 205(b).
Policy
- Healthcare facilities shall submit regulatory reports pursuant to 243 CMR 3.00-3.14 electronically, using the electronic platform designated by the Board, unless they have written confirmation of an exemption. Patient Care Assessment Coordinators are responsible for collaborating with the Board’s Quality and Patient Safety Division staff to ensure their staff are educated as to the completion of the regulatory reports via the established electronic reporting platform.
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- Healthcare facilities for whom electronic reporting will be a hardship shall have the option to seek an exemption by submitting a written request to the Board’s Quality and Patient Safety Division that describes the nature of the hardship. If the Board’s Quality and Patient Safety Committee determines that the hardship warrants an exemption, it will provide written confirmation that the exemption has been approved. Health care facilities that have obtained a written exemption may submit paper reports.
3. The Board’s Quality and Patient Safety Division will accept reports that meet the following criteria:
In satisfaction of the Annual and Semiannual Reports reporting requirements, the Board’s Quality and Patient Safety Division will now accept a single, annual submission to be referred to as the Patient Care Assessment Quality Assurance Report (PCA-QA Report), provided that it includes the following elements:
- A copy of the facility’s Patient Care Assessment Plan, which shall be reviewed, updated, and submitted annually.
The entire updated PCA Plan is to be included.
- Patient complaint data:
- Total volume of patient and family complaints for the reporting period, with the total volume of complaints in each of the top three categories of patient and family complaints.
- Analysis, recommendations, and plans for corrective measures for any trends indicated by data.
In this summary, you should include the data indicated above and provide a brief description of the process to manage complaints. Please provide a brief description if any actions were taken to resolve identified trends or major concerns.
- Performance Improvement Activities (Major Tasks Completed).
This section should contain a description of the major quality improvement initiatives undertaken during the reporting time period. This section should focus on ACTIONS taken to improve patient safety and quality assurance. Please include process or outcome measures where appropriate.
- Internal Reporting and Screening Systems:
- Focused Occurrence Screening Criteria data, analysis, and recommendations.
- Focused Occurrence Reporting Criteria data, analysis, and recommendations.
- Internal Incident Reporting System Data:
- Total number of incident reports for the reporting period, with the total number of incident reports in each of the top three categories of incident reports.
- Analysis, recommendations, and plans for corrective measures for any trends indicated by data.
If a trend is identified in analysis, the following information should be provided: description of the trend and causative factors; a description on any actions recommended or implemented; and follow-up taken or planned by the facility to evaluate the effectiveness of the actions recommended or implemented. If no patterns and trends were identified as a result of data analysis, this should be stated in the report.
A graph or bar chart should be accompanied by analysis, findings, trends and actions, as described above.
See below for examples of Focused Occurrence Reporting Criteria and Focused Occurrence Screening Criteria.
- Attestation that the following elements are in place and available upon request:
- Policy/protocol regarding the distribution of detailed written instructions regarding operational procedures relevant to patient care assessment and compliance with 243 CMR 3.00.
- Policy/protocol regarding the handling of impaired physicians.
- The reporting period is inclusive of the calendar year prior to the report’s due date.
- The PCA-QA Report must be submitted annually on or before the following due dates:
- March 30th for ambulatory clinics and outpatient sites, and
- April 30th for hospitals.
- Healthcare facilities may omit submission of SQR reports of patient falls and pressure injuries provided that:
- The healthcare facility has submitted a semiannual or PCA-QA report within the last 24 months that documents the existence and implementation of comprehensive prevention programs and/or protocols for prevention of patient falls and pressure injuries, and
- The specific patient fall or pressure injury incident is not inclusive of other adverse events.
Examples of Focused Occurrence Reporting Criteria and Focused Occurrence Screening Criteria.
This section of the report should include data on Focused Occurrence Reporting Criteria and Focused Occurrence Screening Criteria. This data should be reported with a numerator and denominator, and contain a rate and a benchmark. The section should also include the following: An analysis of the data. Analysis should also include a description of the facility’s findings and conclusions, based on an aggregate look at the overall performance against the benchmark used (external or internal).