Presentation from Board of Registration in Medicine (PPT) by cuc21142


									MA Board of Registration in Medicine

Patient Care Assessment Program

Patient Safety Workgroup
March 25, 2009

Stancel Riley, MD
Director, PCA Program
Maureen Keenan, RN, JD
Associate Director, PCA Program
 Medical Board Mission

To ensure that only qualified physicians are
licensed to practice in the Commonwealth,
and to support an environment which
maximizes the high quality of health care in
Medical Malpractice Act 1986

Legislative Response to:
   Increased Patient Injuries and Medical Malpractice

   Increased Complaints about Substandard Physician

Legislative Directive:
   Physicians and Health Care Facilities Must
    Participate in “Risk Management” Programs
    Established by Medical Board.
 Statutory Requirements

 Participation in risk management
  programs is a condition of hospital
  licensure (M.G.L. c. 111, § 203(d)).
 Participation in risk management
  programs is a condition of physician
  licensure (M.G.L. c. 112, § 5).
 BORM Regulations Establish
 Patient Care Assessment (PCA) Programs
 243 CMR 3.00, et seq.
“…Primary Goal, Ensuring That Patients in
Both Institutional and Office Settings
Receive Optimal Care.” 243 CMR 3.01
Entities Subject To PCA Regulations

   DPH Licensed Hospitals & Clinics
   State, County, Municipal Hospitals
   HMOs
   Nursing Homes
   Physicians in Private Office Settings
PCA Regulations

Require Programs in:
  Quality Assurance
  Risk Management
  Peer Review
  Identification of Substandard Practice
  Prevention of Substandard Practice

Assure Corporate and Physician Leadership in
                            243 CMR 3.00, et seq.
  DPH Licensed Hospitals & Clinics
 State, County, Municipal Hospitals

Facility Must Have Procedures to Identify &
Analyze Patient Risk, including
  internal incident reporting,
  medical record audit,
  data collection,
  patient complaint process,
  informed consent procedures

Facility Must Have MD Credentialing
 DPH Licensed Hospitals & Clinics
State, County, Municipal Hospitals

PCA Regulations Require Reports to BORM:
 Major Incident Reports (“adverse event
  reports,” aka Safety and Quality Reviews)

 Semi-Annual & Annual Reports (reports
  describing quality assurance/patient safety
Health Maintenance Organizations
(M.G.L. 176G, § 1)

PCA Requirements:
  Processes to Analyze & Resolve Patient
  MD Credentialing Procedures
  Annual Reports to BORM
  Adverse Event Reports to BORM (“Staff
   Model” HMOs, only)
 Nursing Homes
 M.G.L. c. 111, § 71

PCA Regulations Require:
 MD Credentialing Processes
 Copy of DPH Patient Abuse or Serious
  Incident Report To BORM if Event Involves
  a Licensed Physician
Physician Offices

PCA Regulations Require:
 BORM Report: Unplanned Patient Transfer
  To Hospital Precipitated By Procedure in
 BORM Report: Unexpected Serious Patient
  Outcome (death or major disability)
 Allow Onsite Audit by Board
Confidentiality Protections

Information and records necessary to comply
with the Board‟s risk management and quality
assurance programs and necessary to the
work product of medical peer review
committees, including major incident reports
required to be submitted to the Board, are
afforded statutory confidentiality protections.
                       See M.G.L. c. 111, § 204 & 205
     Peer Review Committee

   Be established in Hospitals, Nursing Homes, HMOs
   Evaluate Quality of Health Care
   Determine Whether Cost of Care was Reasonable
   Determine Provider Fitness

Not Available To:
 To Physician Offices
 Communications Between Hospitals

                           See M.G.L. c. 111, § 1
             MA Board Of Registration In Medicine

Physician           Physician     Physician         Physician            Physician          Public           Public
 Board               Board         Board             Board                Board             Board            Board
Member              Member        Member            Member               Member            Member           Member

                      Consumer                         Executive
                       Affairs                          Director

     Enforcement                  Division of       Patient Safety             Licensing                   Physician
       Division                  Law & Policy         Programs                  Division                  Profiles Unit

    Consumer Protection          General Counsel       Patient Care              Initial Licenses         Public Information
    Investigation                Physician Health                                Renewals                 Web Site
                                                       Clinical Skills
    Litigation                   Data Repository                                 Verifications            Call Center
    Clinical Care                                                                Affiliation Agreements
                                                       Liability Reform
PCA Program Structure

PCA Division:
  Director
  Associate Director
  3 Quality Analysts (RNs)
  Administrative Assistant
PCA Program Structure

PCA Committee:
  Board Member
  Medical Experts
  Quality & Patient Safety Experts
  Patient Representative
  Nursing Board Representative
  Pharmacy Board Representative
PCA Activities Include
   Oversight of actual and possible errors
   Trend improvement activities
   Collect at least quarterly safety and quality
    data and analyze reports
   Identify Serious Reportable or Sentinel Events
   Report results back to hospitals with
    emphasis on corrective actions
    PCA Division Review Process

   Health Care Facility Reports

PCA Division Database                  Individual Health Care
                                           Facility Report
                                         Specific Recommendations to
Quality Analyst & Director                    Health Care Facility

                                       System Improvements &
      PCA Committee                         Best Practices
Identify Patterns, Trends, Concerns,              State Wide
        Recommends Action              PCA Updates, Guidelines, Advisories,
                                            Task Forces, Newsletters
   DPH & PCA “Adverse Event” Reports

DPH                                    PCA
Immediate reporting of                 Quarterly reporting of
   “Serious Incidents”                    “Major Incidents”
Reports are public records             Reports are confidential

                Communication and Collaboration

           Eliminate Duplication & Share Lessons Learned
      Hospital PCAC Oversight Example
                           Board of Trustees

Systems                             PCAC                         Credentialed
Review                       Multidisciplinary Review            Provider Review

                        CMO/PCA Coordinator

                       Departmental Review
                 (e.g., Medicine, Surgery, Nursing, Radiology)

                           QI Department

          Incident Reports                     Medical Record/Data Screening
PCA Task Forces
   Physician Credentialing Expert Panel
    Competency–Based Credentialing

   Medical Training Task Force
    Proposed PCA Regulation Changes
PCA Newsletter
Examples of Articles
   BIDMC Develops Quality Measures in OB
   Hyperphosphatemia Alert
   Southcoast Hospitals Reduces Insulin Errors
   PCA Reviews Perinatal SQRs
   “Found Unresponsive” Where, When, Why?
   Hallmark Health Decreases Patient Falls

June ‟08 and December “08
PCA Recognition
“PCA recognizes the following hospitals for demonstrating that
they have quality improvement and patient safety systems
designed to assure that patients receive the highest quality of
care. Safety and Quality Review Reports submitted by these
hospitals provide evidence of multidisciplinary review, multi-
focused investigations, analysis of data, and implementation of
appropriate corrective actions or performance improvement
Berkshire Medical Center      Lowell General Hospital
Caritas Norwood Hospital      New Bedford Rehabilitation Hospital
Emerson Hospital              Newton Wellesley Hospital
HealthAlliance Hospital       Northeast Hospital Corporation
Holyoke Medical Center        North Shore Medical Center

                               PCA Newsletter June „08

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