Code of Massachusetts Regulations
243 CMR - BOARD OF REGISTRATION IN MEDICINE
Title 243 CMR 3.00 - The Establishment Of And Participation In Qualified Patient Care Assessment Programs, Pursuant To M.G.L. c. 112, Section 5, and M.G.L. c. 111, Section 203
Section 3.05 - Qualified Patient Care Assessment Program - Credentialing
Universal Citation: 243 MA Code of Regs 243.3
Current through Register 1531, September 27, 2024
(1) No health care facility in the Commonwealth shall appoint, hire, associate with for the purpose of providing patient care, or grant privileges to a licensee, unless the health care facility first completes the credentialing requirements set forth below. The health care facility must repeat these credentialing requirements at least every two years. These credentialing requirements are modified as follows:
(a) The credentialing requirements may be
performed during the time period in which the health care facility grants
temporary appointment or privileges for up to 120 days in any one year period
to a licensee seeking initial staff membership, provided the health care
facility maintains on file a completed application for staff membership and
written and timely evidence of a valid Massachusetts license, malpractice
insurance, a current DEA certificate of registration for licensees who will be
prescribing controlled substances, and appropriate references; and provided
further that the health care facility pursues in good faith the credentialing
of each licensee holding such temporary appointment or privileges.
(b) The credentialing requirements do not
apply when the health care facility grants temporary appointment or privileges
for up to 30 days in any one year period to a licensee who is not seeking staff
membership, provided the health care facility maintains on file written and
timely evidence of a valid Massachusetts license, malpractice insurance, a
current DEA certificate of registration for licensees who will be prescribing
controlled substances, and letters of recommendation or references as deemed
appropriate by the health care facility.
(2) For the purposes of 243 CMR 3.05, Health Care Facility includes a substantially equivalent facility outside of the Commonwealth.
(3) No health care facility in the Commonwealth shall appoint, hire, associate with for the purpose of providing patient care, or grant to or renew privileges of any licensee unless:
(a) The health care facility verifies that
the licensee holds a current license to practice medicine.
(b) The licensee provides to the health care
facility a copy of his or her most recent application for initial or renewal
registration to practice medicine in the Commonwealth, including all
attachments and other explanatory materials submitted with the application,
whether required or voluntarily submitted. Only to the extent allowed by M.G.L.
c. 151B, § 4, the licensee may delete from such application information
disclosing:
1. an arrest, detention, or
disposition, regarding any violation of law in which no conviction
resulted;
2. a first conviction for
any of the following misdemeanors: drunkenness, simple assault, speeding, minor
traffic violations, affray, or disturbance of the peace; and
3. any conviction of a misdemeanor where the
date of such conviction or the completion of any period of incarceration
resulting therefrom, whichever date is later, occurred five or more years prior
to the date of the credentials application, unless the licensee has been
convicted of any offense within five years immediately preceding the date of
the credentials application.
(c) The licensee provides to the health care
facility a listing and description of all malpractice claims and lawsuits
pending or closed during the previous ten years, including the information
listed in 243 CMR 3.05(3)(e) and any further relevant information requested by
the health care facility. 243 CMR 3.05 applies, whether or not the transaction
giving rise to the malpractice claim arose at the health care facility where
the licensee is seeking or renewing appointment, employment, practice,
association for the purpose of providing patient care, or privileges. 243 CMR
3.05 also applies, whether or not the malpractice claim is filed with an
insurance carrier, a court, or another entity to which the malpractice claim is
presented.
(d) The health care
facility has established criteria for documenting and analyzing, and so
documents and analyzes, where available, a licensee's:
1. professional performance, judgment and
clinical skills;
2. mental and
physical status;
3. compliance with
continuing education requirements;
4. data dealing with utilization;
5. adherence to health care facility and
medical staff bylaws, policies and procedures;
6. malpractice claims filed against the
licensee; and
7. information
regarding any criminal proceedings.
(e) The licensee authorizes his or her
medical malpractice liability insurance carrier or carriers to release to the
health care facility the following information, described in M.G.L. c. 112,
§ 5C, as to claims or actions for damages pending or closed during the
previous ten years, whether or not there has been a final disposition:
1. the policy number of the licensee against
whom the claim is made;
2. the
name, address and age of the claimant or plaintiff;
3. the nature and substance of the
claim;
4. the date and place at
which the claim arose;
5. the
amounts paid, if any, and the date and manner of disposition, judgment,
settlement, or otherwise;
6. the
date and reason for final disposition, if no judgment or settlement;
and
7. such additional information
as the Board shall require pursuant to M.G.L. c. 112, § 5C(g).
(f) The licensee provides to the
health care facility the name of any health care facility where the licensee
has had employment, practice, association for the purpose of providing patient
care, or privileges. The licensee must also provide the reasons for any
discontinuance of employment, practice, association or privileges at any of the
named health care facilities.
(g)
The licensee authorizes release to the health care facility any information
from any other health care facility where the licensee has had employment,
practice, association for the purpose of providing patient care, or privileges,
if such information is relevant, either directly or indirectly, to the
licensee's competence to practice medicine.
(h) The licensee authorizes the health care
facility to exchange information with any other health care facility and with
any professional organization with which the licensee has or had employment,
practice, association or privileges, regarding any pending or final
disciplinary action as defined by
243 CMR
1.01(2), which includes but
is not limited to any voluntary or involuntary course of counseling, treatment
or testing for drug or alcohol abuse.
(i) The health care facility makes reasonable
inquiry to other health care facilities, where the licensee has or has had
employment, practice, association for the purpose of providing patient care, or
privileges, regarding the licensee, before allowing the licensee to practice
medicine at the health care facility. In the case of an initial application,
the health care facility shall make reasonable inquiry of every health care
facility where the licensee has had employment, practice, association for the
purpose of providing patient care, or privileges during at least the previous
ten years. In the case of a renewal appointment, reasonable inquiry shall be
directed to every health care facility where the physician has had employment,
practice, association for the purpose of providing patient care, or privileges
in the previous three years. "Reasonable inquiry" must include up to three
requests, in writing, for:
1. an assessment
of clinical skills; and
2.
information regarding any pending or final disciplinary action, malpractice
litigation, and any other information relevant, either directly or indirectly,
to the licensee's character or competence to practice medicine. In the case of
an inquiry to a health care facility concerning a period of time when the
licensee held a limited license under M.G.L. c. 112, § 9 (or performed
equivalent post-graduate work outside of the Commonwealth), the health care
facility where the licensee had his primary assignment may respond on behalf of
its affiliated health care facilities where the licensee practiced
medicine.
(j) The health
care facility, pursuant to its by-laws or by agreement with the licensee, will
require the licensee to undergo a mental or physical examination, if requested
by
1. the executive committee of the medical
staff or
2. the credentials
committee, or
3. by such other
supervisory body, which includes members of the medical staff, as may be
authorized in the facility's by-laws to make such request;
and if there is a known mental or physical impairment, to provide evidence that the impairment does not interfere with the licensee's competence to practice medicine.
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