The information on this page was last updated by Horty, Springer & Mattern on March 27, 2024.
COLORADO
REPORTING REQUIREMENTS
§ 12-30-206. Governing boards to register with division–annual reports–aggregation and publication of data–definition–rules
(1) As used in this section, “adversely affecting” has the same meaning as set forth except that it does not include a precautionary suspension or any professional review action affecting, for a period of thirty or fewer days, a person licensed under article 240 of this title 12 or an advanced practice nurse.
(2) Each governing board that establishes or uses one or more professional review committees to review the practice of persons licensed under article 240 of this title 12 or of advanced practice nurses shall:
(a) Register with the division in a form satisfactory to the division on or before July 1, 2013, if the governing board has one or more existing professional review committees, or, if the governing board first establishes a professional review committee on or after July 1, 2013, within thirty days after approving the written bylaws, policies, or procedures for the professional review committee;
(a.5) Update the governing board’s information, as specified by the division by rule in accordance with subsection (4)(a) of this section, with the division annually, including whether the governing board is currently engaged in a professional review activity or intends to engage in a professional review activity in the future;
(b) In addition to any other state or federal reporting requirements:
(I) Report annually to the medical board, in a form satisfactory to the medical board, the number of final professional review actions in each of the following categories relating to individuals licensed under article 240 of this title 12:
(A) Adversely affecting the individual;
(B) In which an authorized entity accepted the individual’s surrender of clinical privileges, membership, or affiliation while the individual was under investigation;
(C) In which an authorized entity accepted the individual’s surrender of clinical privileges, membership, or affiliation in return for not conducting an investigation; and
(D) In which the professional review committee made recommendations regarding the individual following a hearing.
(II) Report annually to the nursing board, in a form satisfactory to the nursing board, the number of final professional review actions in each of the following categories relating to advanced practice nurses:
(A) Adversely affecting the individual;
(B) In which an authorized entity accepted the individual’s surrender of clinical privileges, membership, or affiliation while the individual was under investigation;
(C) In which an authorized entity accepted the individual’s surrender of clinical privileges, membership, or affiliation in return for not conducting an investigation; and
(D) In which the professional review committee made recommendations regarding the individual following a hearing.
(c)(I) Report to the division, in a de-identified manner, on its professional review activities during the immediately preceding calendar year in a form satisfactory to the division. These reports must include aggregate data, which is limited to the following:
(A) The number of investigations completed during the year;
(B) The number of investigations that resulted in no action;
(C) The number of investigations that resulted in written involuntary requirements for improvement sent to the subject of the investigation by the authorized entity; and
(D) The number of investigations that resulted in written agreements for improvement between the subject of the investigation and the authorized entity.
(II)(A) The medical board and the nursing board shall forward the reports received pursuant to subsections (2)(b)(I) and (2)(b)(II) of this section, respectively, to the division in a de-identified manner.
(B) The division shall not publish any information identifying the governing board or authorized entity making a report under subsection (2)(b) of this section or this subsection (2)(c), and the reports and information are not public records under the “Colorado Open Records Act”, part 2 of article 72 of title 24.
(III) Reports submitted pursuant to this subsection (2)(c) must include only investigations in which no final action adversely affecting the subject of the investigation was taken or recommended.
(IV) The identity of the governing board reporting the data and the data reported pursuant to this subsection (2)(c) or subsection (2)(b) of this section may be known to the division.
(3)(a) The division shall publish the data provided pursuant to subsections (2)(b) and (2)(c) of this section in aggregate form and without individually identifiable information concerning the governing board, the authorized entity, or any person who was subject to review and is licensed under article 240 of this title 12 or is an advanced practice nurse.
(b) The division shall maintain and shall publish online, through its website, a current list of all governing boards that are registered in accordance with this section and that otherwise are in compliance with this part 2.
(4) The division:
(a) Shall adopt rules to:
(I) Implement this section;
(II) Determine the de-identified information regarding investigations and outcomes a governing board is required to report; and
(III) Establish a process to remove a governing board from the registry when the governing board is no longer required to register with the division pursuant to this section; and
(b) May collect a reasonable registration fee to recover its direct and indirect costs of administering the registration and publication systems required by this section.
(5) For purposes of this section, an investigation occurs when the authorized entity or its professional review committee notifies the subject of the investigation in writing that an investigation has commenced.
(6) The medical board and the nursing board shall not initiate an investigation or issue a subpoena based solely on the data reported pursuant to subsection (2)(c) of this section.
(7)(a) A governing board that fails to register with the division pursuant to subsection (2)(a) of this section is not entitled to any immunity afforded under this part 2 until the date that the governing board so registers. A governing board’s failure to register does not affect any immunity, confidentiality, or privilege afforded to an individual participating in professional review activities.
(b) A governing board’s failure to report as required by this section does not affect any immunity, confidentiality, or privilege afforded to the governing board under this part 2.
§25-3-107 Disciplinary actions reported to Colorado medical board or podiatry board.
(1) Any disciplinary action to suspend, revoke, or otherwise limit the privileges of a licensed physician or podiatrist that is taken by the governing board of a hospital required to be licensed or certified pursuant to this part 1 or required to obtain a certificate of compliance pursuant to section 25-1.5-103(1)(a)(I) or (1)(a)(II) shall be reported to the Colorado medical board or the Colorado podiatry board, whichever board is appropriate, in the form prescribed by said board.
(2) Said hospital shall provide such additional information as is deemed necessary by the Colorado medical board or the Colorado podiatry board to conduct a further investigation and hearing.
3 CCR 713-1:1.12
Formerly cited as 3 CO ADC 713-41:370
713-1:1.12. REPORTING REQUIREMENTS OF SECTIONS 12-30-204(8)(f) AND 12-30-206(2)(b)(I), C.R.S., AND OF THE FEDERAL HEALTH CARE QUALITY IMPROVEMENT ACT OF 1986, AS AMENDED
Amended July 15, 2023
A. Basis: The authority for promulgation of rules and regulations by the Colorado Medical Board (“Board”) is set forth in sections 24-4-103, 12-30-201(1)(a), 12-30-203(1)
B. Purpose: These rules have been adopted by the Board to clarify reporting requirements so that the Board is able to effectively and efficiently utilize and allow professional review committees and governing boards, in order to meet the Board’s responsibilities under Colorado Revised Statutes, Title 12, Article 240. These Rules will enable the Board to more effectively regulate the conduct of the practice of medicine by encouraging prompt, accurate, and complete reporting by governing boards of authorized entities and their professional review committees.
C. Reporting to the Board is required:
1. As obligated under:
a. The federal “Health Care Quality Improvement Act of 1986”, as amended as required by section 12-30-208(2), C.R.S.; and
b. The Professional Review of Health Care Providers as required by sections 12-30-204(7)(f) and 12-30-204(10), C.R.S.; and
c. The Professional Review of Health Care Providers Act as required by section 12-30-206(2)(b)(I), C.R.S.
2. In response to a subpoena issued by the Board in accordance to section 12-30-204(11), C.R.S.
D. Reporting: In order to be considered in compliance with the reporting requirements of this Rule:
1. Reports required under part (A)(1)(a) and (b) of this Rule, must be submitted to the Board within thirty calendar days of the reportable recommendation, finding, or adverse action.
2. Reports required under part (A)(1)(c) of this Rule, the report must be submitted to the Board no later than the first day of March of each year for the information from the preceding calendar year.
3. Paper copies of reports must be sent to the Board’s office by U.S. mail or via electronic mail to the Program Director of the Colorado Medical Board.
4. The Board delegates authority to the Program Director of the Colorado Medical Board to receive the reporting information on its behalf and to resolve reporting discrepancies and irregularities directly with the reporting entity.