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Patient Care Assessment Program Guidance for Hospitals

Here is information and resources to assist hospitals in developing and managing a Patient Care Assessment program

Guidelines for Collection, Analysis and Reporting of Performance Data

In an effort to assess the strength of PCA systems at your facility, the Quality and Patient Safety (QPS) Division sometimes asks for de-identified information about the individual credentialed health care providers involved in events reported in Safety and Quality Reviews.

Additional Resources for Guidelines for Collection, Analysis and Reporting of Performance Data

Patient Care Assessment Plan for Hospitals

The below document summarizes the provisions that must be a hospital's PCA plan, as specified in the Quality and Patient Safety (QPS) regulations, set forth at Chapter 243 of the Code of Massachusetts Regulations, sections 3.01-3.14

Additional Resources for Patient Care Assessment Plan for Hospitals

Semi Annual Reports, Annual Reports & Reporting Schedule

The PCA Semi-Annual Report is essentially a progress report on quality assurance data and activities. It is required by the PCA regulations at 243 CMR 3.07(3)(g). It is prepared for the health care facility's governing body with a copy submitted to the Quality and Patient Safety Division (QPSD). In response to requests from facilities, the QPSD developed a format for semi-annual reporting.

The PCA Annual Report requires certain specific information to be submitted to the QPSD. This information can be found in the PCA regulations at 243 CMR 3.12(4). There is no form per se for this report.

There is a reporting schedule for both the PCA Semi-Annual and Annual Reports. The schedule calls for reports to be submitted on a staggered basis throughout the calendar year; the specific reporting dates vary by type of health care facility.

Additional Resources for Semi Annual Reports, Annual Reports & Reporting Schedule

Safety and Quality Reviews

The Safety and Quality Review (SQR) Form replaces the Major Incident Report form. This is the prescribed form for reporting events that meet “major incident” reporting requirements under the Patient Care Assessment (PCA) regulations, 243 CMR 3.08. The information that you provide in the SQR is protected by statute from public disclosure.

Additional Resources for Safety and Quality Reviews

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