Developing Hospital Advisories for the Massachusetts Quality and Patient Safety Division

State: Massachusetts

Client(s): Massachusetts Board of Registration in Medicine

Service: Applied Research & Evaluation

Technical Expertise: Patient Safety


The Quality and Patient Safety Division (QPSD) at the Board of Medicine oversees institutional systems of quality assurance, risk management, peer review, utilization review and credentialing--known collectively as a Patient Care Assessment (PCA) Program. The QPSD function is unique among the nation's state licensing boards: It is not punitive or adversarial in nature; it does not discipline physicians or regulate their licensure. While its ultimate responsibility is protection of the public, the QPSD is collaborative and educational when working with health care facilities. The QPSD's purpose is to ensure that each health care facility does its job to assure quality and patient safety.

JSI is working with the QPSD to help research and develop hospital advisories about important patient safety and quality improvement issues. All of the hospitals in Massachusetts send quality and safety reports (SQR) that outline quality or patient safety events and the hospital responses. The QPSD staff regularly review the SQRs to ensure effective quality assurance processes. In addition the staff look for themes or trends of broader significance. The hospital advisories are designed to inform hospitals, staff, and providers about recent cases and provide information and resources for quality improvement activities.

As part of this project, JSI will review identified reports selected by the QPSD, do a literature review for guidelines and best practices, and then develop and write the advisories. The advisories will include 1) a review of recent events; 2) illustrative case studies and learning points; 3) strategies for prevention of future events; and 4) a list of resources. Strategies may include standards of care, national guidelines, monitoring and credentialing options for health care facilities, and suggested clinical protocols.

The goal is to educate hospitals about the significance of the events, provide the context including examples and then give a number of potential quality assurance approaches that health care facilities can tailor for the own particular needs.