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 3.14 - Qualified Patient Care Assessment Program- Clinics

Universal Citation: 243 MA Code of Regs 243.3

Current through Register 1531, September 27, 2024

(1) Credentialing. With the exception of 243 CMR 3.14(1)(b), the provisions of 243 CMR 3.05 do not apply to clinics licensed pursuant to M.G.L. c. 111, § 51; however, any such clinic shall not appoint or hire, contract with, contract with any entity to obtain the services of, associate with for the purposes of providing patient care, or grant privileges to a licensee, unless the clinic first performs the following evaluation of the licensee.

(a) The following provisions apply with respect to a licensee who has been or within 90 days will be credentialed or re-credentialed pursuant to 243 CMR 3.05 by a licensed or state hospital within Massachusetts.

1. Prior to the date on which a licensee commences to practice medicine on behalf of a clinic:

a. the clinic shall request and the Massachusetts hospital where the licensee spends the greatest proportion of his or her time (the Primary Hospital) shall provide to the clinic written confirmation that the licensee has been credentialed by the primary hospital pursuant to 243 CMR 3.05. The written confirmation shall be provided to the clinic within 30 days after the later of: receipt of the clinic's request or, subject to 243 CMR 3.14(1)(a), the date on which the licensee is credentialed or re-credentialed pursuant to 243 CMR 3.05 by the primary hospital. The written confirmation shall describe each of the following known to the primary hospital:

i. pending or closed healthcare facility or public agency disciplinary actions against the licensee;

ii. alterations in privileges resulting, directly or indirectly, from concerns about the licensee's professional performance, judgment or clinical skills; and

iii. any other concerns relating to the licensee's professional performance, judgment, clinical skills, or mental or physical status, and any impairment of the licensee related to chemical dependency.

b. The licensee shall provide to the clinic a release and waiver to allow the clinic access to any information in which the licensee has an interest that may be requested by the clinic pursuant to 243 CMR 3.14(1)(a)3.

2. At least once every two years, the clinic shall complete the following process. It shall be completed no later than 60 days after the licensee has been credentialed or re-credentialed pursuant to 243 CMR 3.05 by the primary hospital:

a. The clinic shall complete the process described in 243 CMR 3.14(1)(a)1.a.

3. If the clinic obtains adverse information regarding the licensee pursuant to 243 CMR 3.14(1)(a)1. or 2. or 243 CMR 3.14(1)(b) or (c), the clinic may request in writing and the primary hospital shall provide to the clinic within 30 days, in accordance with M.G.L. c. 111, § 204 and § 205 and M.G.L. c. 111, § 70E, such additional information as the clinic deems necessary to complete its credentialing of the licensee (information identifying particular patients may be redacted). The clinic shall reimburse the primary hospital for the reasonable costs of providing information pursuant to 243 CMR 3.14(1)(a)3.

(b) A licensee who has not been credentialed by a licensed or state hospital within Massachusetts pursuant to 243 CMR 3.05 shall be credentialed by the clinic pursuant to 243 CMR 3.05 prior to the date on which the licensee commences to practice medicine on behalf of the clinic, and biennially thereafter.

(c) The clinic shall perform an initial and biennial credentialing evaluation of the licensee, based on the information obtained pursuant to 243 CMR 3.14(1)(a) or (b), as applicable, and based on information developed by the clinic's Patient Care Assessment program. The evaluation shall include assessment of the licensee's professional performance, judgment and clinical skills.

(d) Based on information received or developed by the clinic, the clinic shall provide in writing to any health care facility credentialing a licensee, upon written request by that facility, an assessment of the licensee's clinical skills, information regarding disciplinary actions and malpractice litigation, and other relevant information related to the licensee's competence to practice medicine. The clinic may summarize information obtained pursuant to 243 CMR 3.14(1)(a)3. in order to fulfill the credentialing requirements of 243 CMR 3.01, but it shall not re-disclose such information without the prior written consent of the primary hospital from which it was received.

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