Mass. Gen. Laws ch. 111, sec. 203 — MA Code / Part I / Title XVI / Chapter 111 / Section 203
Health care provider misconduct; medical peer review
Status: in_force

Section 203. (a) The by-laws of every licensed or public hospital and the by-laws of all medical staffs shall contain provisions for reporting conduct by a health care provider that indicates incompetency in his specialty or conduct that might be inconsistent with or harmful to good patient care or safety. Said by-laws shall direct a procedure for investigation, review and resolutions of such reports. (b) Whenever, following review by a medical peer review committee of a licensed or public hospital determination is reached that a health care provider's privileges should be suspended in the best interests of patient care, such committee shall immediately forward the recommendation to the executive committee of the medical staff and the institution's board of trustees for action. A provider whose privileges are suspended shall be entitled to notice and a prompt hearing following suspension, in accordance with the institution's medical staff by-laws. (c) An individual or institution, including a licensed or public hospital, physician credentialing verification service operated by a society or organization of medical professionals for the purpose of providing credentialing information to health care entities, or licensed nursing home reporting, providing information, opinion, counsel or services to a medical peer review committee, or participation in the procedures required by this section, shall not be liable in a suit for damages by reason of having furnished such information, opinion, counsel or services or by reason of such participation, provided, that such individual or institution acted in good faith and with a reasonable belief that said actions were warranted in connection with or in furtherance of the function of said committee or the procedures required by this section. (d) Every licensed hospital, as a condition of licensure, and every public hospital shall be required to participate in risk management programs established by the board of registration in medicine pursuant to section five of chapter one hundred and twelve; provided, however, that licensed or public hospitals which participate in pre-existing risk management programs may be exempted by regulations of the board from the requirements of this paragraph. (e) Every licensed nursing home shall: (i) request from every physician providing medical care in the nursing home said physician's name and license number; (ii) upon initial appointment of its medical director or physician advisor and biennially thereafter, inquire from a hospital where the physician has staff privileges and spends the greatest portion of his time, the status of said physician's staff privileges, or if the physician has no such staff privileges, make such reasonable inquiry, as the board of registration in medicine by regulation may require, into the physician's employment history and malpractice claims experience; (iii) report to said board any disciplinary action which the nursing home takes against any physician providing medical care in the nursing home; the nursing home shall report to the board any disciplinary action within thirty days of the occurrence of the reportable action; the report shall include a statement detailing the nature and circumstances of the action, its date, and the reasons for it; the nursing home shall file an annual disciplinary summary with the board; the annual disciplinary summary shall be filed no later than January thirty-first for each previous calendar year. The annual disciplinary summary shall summarize the reports submitted for the previous calendar year; the annual disciplinary summary shall be sent by certified or registered mail, and it shall be under oath; if the nursing home submitted no reports for the previous calendar year, then the annual disciplinary summary shall state that no reports were required; and (iv) simultaneously send to said board a copy of any report sent to the department of public health pursuant to the provisions of sections seventy-one and seventy-two, whenever any such report indicates incompetency of a physician or other conduct by a physician that seriously affects a nursing home patient's health and safety. The types of incidents reported under this section, shall be jointly determined by the department of public health and the board of registration in medicine and may be set forth in regulations promulgated by the board. (f) Every service, EMS first responder, emergency medical technician, every trauma center and regional EMS council licensed, certified or designated pursuant to chapter 111C, every physician providing medical direction under said chapter and every hospital affiliated with any such service shall participate in continuous quality improvement programs established under chapter 111C by the state medical director or by a regional medical director and conducted under said chapter by a medical peer review committee to review and evaluate the necessity, quality and effectiveness of the emergency medical care and specialty care services, including, without limitation, trauma care services in the commonwealth. (g) A licensed pharmacy may establish a pharmacy peer review committee to evaluate the quality of pharmacy services or the competence of pharmacists and suggest improvements in pharmacy systems to enhance patient care. The committee may review documentation of quality-related activities in a pharmacy, assess system failures and personnel deficiencies, determine facts, and make recommendations or issue decisions in a written report that can be used for contiguous quality improvement purposes. A pharmacy peer review committee shall include the members, employees, and agents of the committee, including assistants, investigators, attorneys, and any other agents that serve the committee in any capacity.

Section 203. (a) The by-laws of every licensed or public hospital and the by-laws of all medical staffs shall contain provisions for reporting conduct by a health care provider that indicates incompetency in his specialty or conduct that might be inconsistent with or harmful to good patient care or safety. Said by-laws shall direct a procedure for investigation, review and resolutions of such reports.

(b) Whenever, following review by a medical peer review committee of a licensed or public hospital determination is reached that a health care provider's privileges should be suspended in the best interests of patient care, such committee shall immediately forward the recommendation to the executive committee of the medical staff and the institution's board of trustees for action. A provider whose privileges are suspended shall be entitled to notice and a prompt hearing following suspension, in accordance with the institution's medical staff by-laws.

(c) An individual or institution, including a licensed or public hospital, physician credentialing verification service operated by a society or organization of medical professionals for the purpose of providing credentialing information to health care entities, or licensed nursing home reporting, providing information, opinion, counsel or services to a medical peer review committee, or participation in the procedures required by this section, shall not be liable in a suit for damages by reason of having furnished such information, opinion, counsel or services or by reason of such participation, provided, that such individual or institution acted in good faith and with a reasonable belief that said actions were warranted in connection with or in furtherance of the function of said committee or the procedures required by this section.

(d) Every licensed hospital, as a condition of licensure, and every public hospital shall be required to participate in risk management programs established by the board of registration in medicine pursuant to section five of chapter one hundred and twelve; provided, however, that licensed or public hospitals which participate in pre-existing risk management programs may be exempted by regulations of the board from the requirements of this paragraph.

(e) Every licensed nursing home shall: (i) request from every physician providing medical care in the nursing home said physician's name and license number; (ii) upon initial appointment of its medical director or physician advisor and biennially thereafter, inquire from a hospital where the physician has staff privileges and spends the greatest portion of his time, the status of said physician's staff privileges, or if the physician has no such staff privileges, make such reasonable inquiry, as the board of registration in medicine by regulation may require, into the physician's employment history and malpractice claims experience; (iii) report to said board any disciplinary action which the nursing home takes against any physician providing medical care in the nursing home; the nursing home shall report to the board any disciplinary action within thirty days of the occurrence of the reportable action; the report shall include a statement detailing the nature and circumstances of the action, its date, and the reasons for it; the nursing home shall file an annual disciplinary summary with the board; the annual disciplinary summary shall be filed no later than January thirty-first for each previous calendar year. The annual disciplinary summary shall summarize the reports submitted for the previous calendar year; the annual disciplinary summary shall be sent by certified or registered mail, and it shall be under oath; if the nursing home submitted no reports for the previous calendar year, then the annual disciplinary summary shall state that no reports were required; and (iv) simultaneously send to said board a copy of any report sent to the department of public health pursuant to the provisions of sections seventy-one and seventy-two, whenever any such report indicates incompetency of a physician or other conduct by a physician that seriously affects a nursing home patient's health and safety. The types of incidents reported under this section, shall be jointly determined by the department of public health and the board of registration in medicine and may be set forth in regulations promulgated by the board.

(f) Every service, EMS first responder, emergency medical technician, every trauma center and regional EMS council licensed, certified or designated pursuant to chapter 111C, every physician providing medical direction under said chapter and every hospital affiliated with any such service shall participate in continuous quality improvement programs established under chapter 111C by the state medical director or by a regional medical director and conducted under said chapter by a medical peer review committee to review and evaluate the necessity, quality and effectiveness of the emergency medical care and specialty care services, including, without limitation, trauma care services in the commonwealth.

(g) A licensed pharmacy may establish a pharmacy peer review committee to evaluate the quality of pharmacy services or the competence of pharmacists and suggest improvements in pharmacy systems to enhance patient care. The committee may review documentation of quality-related activities in a pharmacy, assess system failures and personnel deficiencies, determine facts, and make recommendations or issue decisions in a written report that can be used for contiguous quality improvement purposes. A pharmacy peer review committee shall include the members, employees, and agents of the committee, including assistants, investigators, attorneys, and any other agents that serve the committee in any capacity.