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Health Care Facility Disciplinary Action Reports FAQs

Frequently-asked questions regarding mandated facility reporting

The Board provides the following questions and answers for guidance. These are hypothetical examples of general situations, and may not apply to your particular situation. These responses are not a substitute for legal advice, nor does the Board provide legal advice to health care facilities. In determining whether a particular action is reportable, a health care facility should consult its own legal counsel.

FAQs

What is a reportable disciplinary action?
The regulations for the Board of Medicine, found at 243 CMR 3.02, define what disciplinary actions must be reported to the Board. A copy of that definition is included at the end of these instructions.

Some types of disciplinary actions must always be reported to the Board, even if based on a disciplinary action taken by the Board or another health care facility. For example, the revocation or suspension of a physician's hospital privileges is always reportable.

Other types of disciplinary actions must be reported only if they relate to the physician's competence to practice medicine, or to a violation of law, regulation or by-law.
The Board has interpreted "related to...a violation of law, regulation or by-law" as pertaining to laws and regulations related to the practice of medicine. However, the Board interprets "related to the practice of medicine" broadly. It includes conduct or behavior directed towards other health care providers that takes place on hospital grounds and that has affected or could have affected patient care.

Although a facility may not have to file an HCFD report if it learns of a physician's violation that was not related to the practice of medicine, it may still have a legal duty to report to the Board pursuant to G.L. chapter 112, §5F dealing with reports of violations by health care providers.

What if a disciplinary action was taken based on personality issues?
Personality issues, per se, may not need to be reported to the Board. However, if the physician's personality problems affect patient care, the action should be reported. Examples include refusing to listen to other providers' suggestions regarding treatment decisions, confrontations/altercations with other staff in front of patients and refusal to work with other staff members that result in delayed treatment.

How many forms do I need to file for one disciplinary action?
This will vary depending on the action taken. Here are some examples.

On January 1, the facility imposed two actions at the same time on a physician, (for example, a reprimand and a privilege restriction). File one Initial Report (Form HCFD-1), then file a Subsequent Report, (Form HCFD-2), every 60 days for the duration of the disciplinary actions.

On January 1, the facility imposed a monitoring arrangement on a physician. On February 1, the facility suspended that same physician. Here you need to file two Form HCFD-1 Initial Reports, one for each of the disciplinary actions because they were taken at different times.

How do I "substantiate" an HCFD report?
Be specific about the allegations. Here is an example of adequate substantiation.

"A number of patient complaints resulted in a department-wide review, which concluded that Dr. Black's care fell below the usual and customary standards expected in our facility. The complaints included allegations of rudeness, failure to diagnose a fracture and failure to diagnose and treat an MI."

Here is an example of inadequate substantiation. "Action resulted from cases or concerns generated during peer review." The Board will return reports filed with inadequate substantiation and has authority to impose fines for violation of this statutory requirement.

When is a disciplinary action "related to competence" and therefore reportable?
"Competence" includes, but is not limited to, technical proficiency, sound medical judgment and a fund of knowledge necessary to meet the applicable standard of care.

If a physician recognizes his/her own problem, and voluntarily initiates an action to address it, the Board may interpret this as not related to competence, and therefore not reportable by a health care facility on an HCFD report.

However, when a health care facility receives complaints or when incident reports prompt a review of the physician's practice, a report must be filed. When issues are raised during the credentialing process, a report should be filed. The facility must report even if the physician subsequently agrees to a suggested remedial course of action.

In addition, the Board interprets "related to competence" as including situations in which a physician withdraws an application or agrees to the imposition of a disciplinary action while the facility is conducting an investigation, even when the facility does not make a final determination on the subject(s) of the investigation.

Examples:

  • An aging surgeon recognizes that surgery is becoming more difficult, and limits himself to serving as an assistant surgeon: Not Reportable.
  • Residents, surgical assistants and/or nurses file incident reports alleging that a surgeon is increasingly confused, and others often need to take over; hospital approaches surgeon and she agrees to limit her practice to assisting: Reportable.
  • Physician recognizes an impairment, and requests a leave of absence to enter a substance abuse program: Not Reportable, as long as there is no evidence of risk of patient harm due to his impairment.
  • Facility learns of physician's impairment, approaches him/her and asks her/him to take a leave of absence to obtain treatment: Reportable. Please note: While M/G/L/ Ch. 112, s. 5F may have an exception for reporting impairment, there is no such exception in MGL c. 111 §§53B and 203. A health care provider may not be required to report a physician's "impairment" pursuant to the impairment exception of G.L. c. 112, §5F (further discussed at 243 CMR 2.07(23)). However, a health care facility has a statutory obligation to file a disciplinary action report in cases involving impairment when the facility initiates the action or inquiry, or when the physician's self-reported impairment might put patients at risk.
  • Physician denied privileges because she is not board certified or cannot be on-call the required number of hours per week: Not reportable.
  • During a merger of Hospital A and Hospital B, Hospital B decides to grant a physician only some of the privileges for which he was credentialed at Hospital A based on a review of the physician's record at Hospital A. Reportable.

The physician that is the subject of the disciplinary action holds a temporary license. Is the action reportable?
Yes. Actions that fall within the definition of "disciplinary action" must be reported regardless of the type of license held by the physician (limited or full) and regardless of the type of privileges held by the physician (full, temporary, courtesy, etc.).

The disciplinary action was taken by the Chief of Medicine. Is it reportable?
Yes, the action is reportable no matter who imposed it, so long as that individual or entity is authorized by the facility to impose disciplinary actions. An otherwise reportable disciplinary action is reportable whether it was imposed by an individual or by an entity, for example, a Medical Executive Committee or a Board of Trustees.

Are disciplinary actions that occur during a credentialing process reportable?
Yes, if the action is otherwise reportable, it does not matter when the action was imposed. Disciplinary actions are reportable when they occur during credentialing or recredentialing or at any other time.

What information from the HCFD Forms will be published on a Physician's Profile?
State law requires that the Board publish certain types of hospital disciplinary actions on a physician's public profile. The Board publishes the following information:
a description of revocation or involuntary restriction of hospital privileges for reasons related to competence or character that have been taken by the hospital's governing body or any other official of the hospital after procedural due process has been afforded,

or

the resignation from or non-renewal of medical staff membership or the restriction of privileges at a hospital taken in lieu of or in settlement of a pending disciplinary case related to competence or character in that hospital.

The Board assumes that the facility has afforded the physician procedural due process, when applicable, unless otherwise notified.

The language used on the Physician Profiles is derived from the information reported by the facility on the HCFD forms. The Board uses the basis codes chosen by the hospital to describe the disciplinary action taken. Therefore, questions on this language should be directed to the health care facility reporter. The date of the action and the end date, if applicable, are also based upon what has been provided to the Board in the HCFD reports.

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