Patient Care Assessment Program Guidance for Licensed Ambulatory Surgical Centers & Clinics

Here is information and resources to assist Licensed Ambulatory Surgical Centers & Clinics with an approved exemption from online Patient Care Assessment reporting

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

May 2010: Performance Data Guideline

Patient Care Assessment Plan for ASCs & Clinics

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

Patient Care Assessment Plan for ASCs and Clinics

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

Safety and Quality Review Form

SQR Instructions

Safety and Quality Review Report Tutorial

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

ASC Instructions for Semi Annual Report, Annual Report Guidelines and Reporting Schedule

Summary Chart of Patient Care Assessment Reporting Requirements

Safety and Quality Review Report Tutorial

Workshops

There are no workshops scheduled at this time.  Future workshops will be posted as is appropriate.