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Quality & Patient Safety - Frequently Asked Questions

Here are the answers to common questions about the Board's Quality & Patient Safety programs

Q. When are Safety and Quality Reviews due?
A. Technically, a health care facility has 30 days following the end of the calendar quarter in which the Safety and Quality issue occurred to submit a report to the Quality and Patient Safety Division (QPSD). The intention of this "quarterly reporting" is to give facilities approximately three months to investigate an issue before filing the Safety and Quality Review with the Board.

Q. Should I wait until the investigation of an incident is complete before filing a report?
A. If the investigation will take (approximately) three months or less, yes, you may wait until the investigation is complete before submitting a report. If the investigation is likely to take more than three months, you should file an initial report with as much information as possible and then submit a follow-up report when the investigation is completed. If you do submit an initial report, you must be sure to submit a follow-up report when the investigation is closed.

Q. If no major Safety and Quality issues occur in a particular calendar quarter, do I have to submit some kind of report stating so?
A. Although some hospitals do submit a written statement that no major issues have occurred in the most recent quarter, it is not necessary to do so.

Q. What if I am not sure whether an event meets the definition of a Safety and Quality issue?
 Call the QPSD for guidance and assistance.

Q. There is a new PCA Coordinator at our health care facility. Do we have to do anything?
A. The PCA regulations require (at 243 CMR 3.06(2)) that the health care facility report the name of the PCA Coordinator to the QPSD within ten days of designation or replacement.

Q. When are my facility's PCA Semi-Annual and Annual reports due? Are there formats or forms for these reports?
 There is no form but there is a recommended format for PCA Semi-Annual reports. There is no form per se for the PCA Annual report, however, the information that must be contained in the report can be found at 243 CMR 3.11(4). Please call the QPSD or see the QPSD section of the Board's website for: (1) the recommended format for the PCA Semi-Annual report; (2) the information that must be included in the PCA Annual report; and (3) a reporting schedule for PCA Semi-Annual and Annual reporting.

Q. I am confused about PCA Annual reporting - is it the same as the Annual Disciplinary Action Summary report? Please clarify.
A. Please see the above question for information on PCA Annual reporting. The PCA Annual report is DIFFERENT from the Board's Annual Disciplinary Action Summary report. The latter report, which asks for information about the physicians who were disciplined by the health care facility in the previous year, go to a completely different unit in the Board: the Data Repository Unit.

Q. How long should I keep the credentialing files for our physicians?
 The PCA regulations (at 243 CMR 3.11(1)(d)) state that the health care facility must maintain personnel records regarding its health care providers for a minimum of ten years. This regulation deals only with the Board's requirements - there may be other state laws and regulations that require organizations to maintain personnel files for a longer period of time.