Massachusetts Peer Review Statute

The information on this page was last updated by Horty, Springer & Mattern on August 24, 2017.

MASSACHUSETTS

PEER REVIEW

Mass. Gen. Laws Ann. Ch. 111 §1. Definitions.

The following words as used in this chapter, unless a different meaning is required by the context or is specifically prescribed, shall have the following meanings:

“Board of health” shall include the board or officer having like powers and duties in towns where there is no board of health.

“Commissioner”, the commissioner of public health.

“Council”, the public health council of the department of public health.

“Department”, the department of public health.

“Disease dangerous to the public health” shall include all diseases defined as such in accordance with section six.

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“Health care provider”, any doctor of medicine, osteopathy, or dental science, or a registered nurse, social worker, doctor of chiropractic, or psychologist licensed under the provisions of chapter one hundred and twelve, or an intern, or a resident, fellow, or medical officer licensed under section nine of said chapter one hundred and twelve, or a hospital, clinic or nursing home licensed under the provisions of chapter one hundred and eleven and its agents and employees or a public hospital and its agents and employees.

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“Medical peer review committee” or “committee”, a committee of a state or local professional society of health care providers, including doctors of chiropractic, or of a medical staff of a public hospital or licensed hospital or nursing home or health maintenance organization organized under chapter one hundred and seventy-six G, provided the medical staff operates pursuant to written by-laws that have been approved by the governing board of the hospital or nursing home or health maintenance organization or a committee of physicians established pursuant to section 12 of chapter 111C for the purposes set forth in subsection (f) of section 203,which committee has as its function 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, the determination whether the cost of health care services were performed in compliance with the applicable standards of care, determination whether the cost of the 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; provided, however, that for purposes of sections two hundred and three and two hundred and four, a nonprofit corporation, the sole voting member of which is a professional society having as members persons who are licensed to practice medicine, shall be considered a medical peer review committee; provided, further, that its primary purpose is the evaluation and assistance of health care providers impaired or allegedly impaired by reason of alcohol, drugs, physical disability, mental instability or otherwise.  “Medical peer review committee” shall include a committee of a pharmacy society or association that is authorized to evaluate the quality of pharmacy services or the competence of pharmacists and suggest improvement in pharmacy systems to enhance patient care; or a pharmacy peer review committee established by a person or entity that owns a licensed pharmacy or employs pharmacists that is authorized to evaluate the quality of pharmacy services or the competence of pharmacists and suggest improvements in pharmacy systems to enhance patient care.

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“Primary care provider”, a health care professional qualified to provide general medical care for common health care problems who; (1) supervises, coordinates, prescribes, or otherwise provides or proposes health care services; (2) initiates referrals for specialist care; and (3) maintains continuity of care within the scope of practice.

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111 §203. Health care provider misconduct; medical peer review.

(a) The bylaws of every licensed or public hospital and the bylaws 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 bylaws 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 bylaws.

(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 functions 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.

111 §204. Confidentiality of medical peer review committee proceedings, reports and records; exceptions; immunity.

(a) Except as otherwise provided in this section, the proceedings, reports and records of a medical peer review committee shall be confidential and shall be exempt from the disclosure of public records under Section 10 of Chapter 66 but shall not be subject to subpoena or discovery, or introduced into evidence, in any judicial or administrative proceeding, except proceedings held by the board of registration in medicine, pharmacy, social work, or psychology or by the department of public health pursuant to chapter 111C, and no person who was in attendance at a meeting of a medical peer review committee shall be permitted or required to testify in any such judicial or administrative proceeding, except proceedings held by the board of registration in medicine, pharmacy, social work, or psychology or by the department of public health pursuant to chapter 111C, as to the proceedings of such committee or as to any findings, recommendations, evaluations, opinions, deliberations or other actions of such committee or any members thereof.

(b) Documents, incident reports or records otherwise available from original sources shall not be immune from subpoena, discovery or use in any such judicial or administrative proceeding merely because they were presented to such committee in connection with its proceedings. Nor shall the proceedings, reports, findings and records of a medical peer review committee be immune from subpoena, discovery or use as evidence in any proceeding against a member of such committee to establish a cause of action pursuant to section eighty-five N of chapter two hundred and thirty-one; provided, however, that in no event shall the identity of any person furnishing information or opinions to the committee be disclosed without the permission of such person. Nor shall the provisions of this section apply to any investigation or administrative proceeding conducted by the boards of registration in medicine, social work or psychology or by the department of public health pursuant to chapter 111C.

(c) A person who testifies before such committee or who is a member of such committee shall not be prevented from testifying as to matters known to such person independent of the committee’s proceedings, provided that, except in a proceeding against a witness to establish a cause of action pursuant to section eighty-five N of chapter two hundred and thirty-one, neither the witness nor members of the committee may be questioned regarding the witness’ testimony before such committee, and further provided that committee members may not be questioned in any proceeding about the identity of any person furnishing information or opinions to the committee, opinions formed by them as a result of such committee proceedings, or about the deliberations of such committee.

(d) A court or administrative body may place reasonable restrictions on the use which may be made of the information obtained hereunder so as to maintain, so far as necessary or practicable, the confidentiality of such information.

(e) No proceeding, report or record of a medical peer review committee obtained hereunder and disclosed in an action pursuant to section eighty-five N of chapter two hundred and thirty-one or a proceeding before an administrative body, shall be subject to subpoena or discovery, or introduced into evidence in judicial or administrative proceedings other than those proceedings or investigations specified in subsections (a) and (b).

111 §205. Information and records necessary to comply with risk management and quality assurance programs; confidentiality; definitions.

(a) As used in this section the following terms shall have the following meanings:

“Health care facility”, any entity required to participate in risk management and quality assurance programs established by the board of registration in medicine.

“Patient care assessment coordinator”, a person or committee designated by a health care facility to implement and coordinate the facility’s compliance with risk management and quality assurance programs established by the board of registration in medicine.

“Risk management and quality assurance programs established by the board of registration in medicine”, programs and activities undertaken pursuant to regulations promulgated by the board of registration in medicine under section two hundred and three of this chapter and sections five and five I of chapter one hundred and twelve.

(b) Information and records which are necessary to comply with risk management and quality assurance programs established by the board of registration in medicine and which are necessary to the work product of medical peer review committees, including incident reports required to be furnished to the board of registration in medicine or any information collected or compiled by a physician credentialing verification service operated by a society or organization of medical professionals for the purpose of providing credentialing information to health care entities shall be deemed to be proceedings, reports or records of a medical peer review committee for purposes of section two hundred and four of this chapter and may be so designated by the patient care assessment coordinator; provided, however, that such information and records so designated by the patient care assessment coordinator may be inspected, maintained and utilized by the board of registration in medicine, including but not limited to its data repository and disciplinary unit. Such information and records inspected, maintained or utilized by the board of registration in medicine shall remain confidential, and not subject to subpoena, discovery or introduction into evidence, consistent with section two hundred and four; however, such records may not remain confidential if disclosed in an adjudicatory proceeding of the board of registration in medicine, but the information and records shall be otherwise subject to the protections afforded by section two hundred and four. In no event, however, shall records of treatment maintained pursuant to section seventy of this chapter, or incident reports or records or information which are not necessary to comply with risk management and quality assurance programs established by the board of registration in medicine be deemed to be proceedings, reports or records of a medical peer review committee under this section; nor shall any person be prevented by the provisions of this section from testifying as to matters known by such person independent of risk management and quality assurance programs established by the board of registration in medicine.

112 §5G. Communication with professional organizations or board; liability; counsel fees and costs.

(a) No person or health care provider who communicates with a peer review committee, administrative subcommittee, ethics committee or other similar committee of a health care provider, professional society of health care providers or entity which pays professional liability claims on behalf of any health care provider shall be liable in any cause of action arising out of the providing or receiving of such communication provided that such person or health care provider acts in good faith and with a reasonable belief that such communication was warranted in connection with or in furtherance of the functions of such committee.

(b) No person who reports information to the board as required in section five A through section five F inclusive, or as required in any other law or regulation shall be liable in any cause of action arising out of such report provided that such person acts in good faith and with a reasonable belief that such report was required. If such an action is instituted against a person who reports to the board as required in sections five A to five F, inclusive, and such action is determined by the court to be insubstantial, frivolous and not advanced in good faith, then such person defending such action may be awarded reasonable counsel fees and other costs and expenses incurred in defending against such action pursuant to section six F of chapter two hundred and thirty-one.

231 §85N. Liability of licensed members of certain professional societies and committees for damages resulting from official acts.

No member of a professional society or of a duly appointed committee thereof, or a duly appointed member of a committee of a medical staff of a licensed hospital or a health maintenance organization licensed under the provisions of chapter one hundred and seventy-six G shall be liable in a suit for damages as a result of his acts, omissions or proceedings undertaken or performed within the scope of his duties as such committee member, provided that he acts in good faith and in the reasonable belief that based on all of the facts the action or inaction on his part was warranted; nor shall an individual be liable in a suit for damages as a result of acts, omissions or proceedings undertaken or performed within the scope of his duties to a nonprofit corporation, the sole voting member of which is a professional society having as members persons who are licensed to practice medicine; provided, however, that such individual acts in good faith and in the reasonable belief that based on all of the facts the action or inaction on his part was warranted.

For the purposes of this section “professional society” shall mean a society having as members persons who are licensed or admitted to practice in the field of law, medicine, chiropractic, optometry, psychiatry or psychology, dentistry, accounting, engineering, land surveyor, as set forth in section eighty-one D of chapter one hundred and twelve, architecture or social work.