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Quality and Safety Program

The Quality and Patient Safety Division (QPSD) provides oversight of institutional systems of quality assurance, risk management, peer review, utilization review, and credentialing


The function of the Quality and Patient Safety Division (QPSD) at the Board of Medicine is the oversight of institutional systems of quality assurance, risk management, peer review, utilization review and credentialing, known collectively as a Patient Care Assessment (PCA) Program. The systems comprising a health care facility's PCA program must be overseen by both physician and corporate leadership and must actively involve all health care providers and most employees at the institution.

The Board's QPSD function was mandated by the Medical Malpractice Reform Act of 1986. The key provisions of the Massachusetts General Laws dealing with the Board's oversight of institutional quality assurance are M.G.L. c. 111, § 203(d) and M.G.L. c. 112, § 5. These statutes include the requirements that participation in PCA programs is a condition of both hospital and physician licensure.

Following the enactment of these statutes, the Board promulgated regulations to carry out its legal mandate of overseeing institutional quality assurance. These regulations, known as the PCA Regulations and found at 243 CMR 3.00, specify in detail the requirements broadly set out in the 1986 legislation. The regulations apply to health care facilities, ranging from hospitals to physicians' office settings, and include the requirement that physicians licensed in Massachusetts may not provide patient care at facilities without PCA programs.

The QPSD function is unique among the nation's state licensing boards. The Board's QPSD activities differ from its other more traditional functions. The QPSD is not punitive or adversarial in nature; it does not discipline physicians or regulate their licensure. While its ultimate responsibility is protection of the public, the QPSD is collaborative and educational when working with health care facilities. The QPSD's purpose is to ensure that each health care facility does its job to assure quality; to accomplish that end, it attempts to work collegially with facilities.

The QPSD and it's Committee are also unique in the confidential nature of their activities. Soon after the inception of the QPSD function at the Board, the legislature passed a statute that afforded PCA information a high level of legal protection from disclosure (M.G.L. c. 111, § 205). The statute provides that PCA information is confidential and not subject to subpoena, discovery or introduction into evidence.

Facility PCA coordinators may use the link below to prepare a Safety & Quality Review for submission to the QPSD. For your convenience, you may fill out the form as a PDF, then print it, sign it, and mail it to the QPSD.

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