243 CMR 3.06 - Qualified Patient Care Assessment Program - Structure
(1) The health care facility shall establish
a medical peer review committee, within the meaning of M.G.L. c. 111, § 1,
with responsibility for patient care assessment at the governing body level, to
be known as the Patient Care Assessment Committee.
(a) The governing body shall assure the
adequacy of resources and support systems for the Patient Care Assessment
Committee functions. In lieu of establishing a single Patient
Care Assessment Committee, the governing body may elect to establish or
maintain separate board level medical peer review committees to carry out the
Patient Care Assessment Committee functions required by
243 CMR 3.00. A governing
board level committee shall include at least one member of the governing
body.
(b) The health care facility
may have any other peer review committees as it deems appropriate.
(c) The Patient Care Assessment Committee or
the committees carrying out patient care assessment committee functions may:
1. be comprised of persons not only from the
medical staff; and
2. consistent
with the definition of Medical Peer Review Committee
under M.G.L. c. 111, § 1, carry out all or some of the following
functions: the evaluation or improvement of the quality of health care rendered
by providers of health care services, the determination whether health care
services were performed in compliance with the applicable standards of care,
determination whether the cost of health care services rendered was considered
reasonable by the providers of health services in the area, the determination
of whether a health care provider's actions call into question such health care
provider's fitness to provide health care services, or the evaluation and
assistance of health care providers impaired or allegedly impaired by reason of
alcohol, drugs, physical disability, mental instability or otherwise.
(2) The governing body
shall designate a Patient Care Assessment Coordinator, who shall be charged by
the governing body with responsibility for implementing, by delegation,
oversight, facilitating, coordinating, or otherwise, the health care facility's
Qualified Patient Care Assessment Program and with ensuring compliance with
243 CMR 3.00. In
lieu of appointing a single Patient Care Assessment
Coordinator, the governing body of a health care facility may designate a
committee to carry out the Patient Care Assessment Coordinator's functions as
enumerated in
243 CMR 3.00. Thus, upon
election of the health care facility's governing body, all references herein to
Patient Care Assessment Coordinator may include the
Patient Care Assessment Committee. The Patient Care
Assessment Coordinator shall be responsible to the Patient Care Assessment
Committee or shall be the formal administrative link amongst any separate
committees which carry out the patient care assessment functions required by
243 CMR 3.00. The health care
facility shall report the name of the Patient Care Assessment Coordinator to
the Board within ten days of designation or replacement. The Patient Care
Assessment Coordinator may be a qualified physician or a qualified
non-physician.
(3) The Patient Care
Assessment Coordinator shall prepare and distribute detailed written
instructions regarding operational procedures relevant to patient care
assessment and compliance with
243 CMR 3.00. The Patient Care
Assessment Coordinator shall distribute such written instructions as are
relevant to each health care provider at the health care facility. As part of
the annual report under
243
CMR 3.12(4), the health care
facility shall file the written instructions with the Board.
(4) The Patient Care Assessment Coordinator
shall have unrestricted access to all records and information related to the
Patient Care Assessment Coordinator's functions as per
243 CMR 3.00.
Notes
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