DEPARTMENT OF REGULATORY AGENCIES Colorado Medical Board Rule 350 - DESIGNATION OF HEALTH SYSTEM AFFILIATIONS WHICH ARE AUTHORIZED TO ESTABLISH PROFESSIONAL REVIEW COMMITTEES 3 CCR 713-1 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] INTRODUCTION A. BASIS. The authority for promulgation of rules and regulations by the Colorado Medical Board(“Board” ) is set forth in Sections 24-4-103, 12-36-104(1)(a) and 12-36.5-104(5), C.R.S.

B. PURPOSE. These rules have been adopted by the Board to:

1. 1. Establish standards for the designation of Health System Affiliations authorized by the Board to establish professional review committees in order that such Health System Affiliations will be entitled to the immunities and confidentiality provided by Section 12-36.5-101, et
   1. seq. , C.R.S.
2. 2. Effectuate the legislative policy set forth in Section 12-36.5-101, et seq. , C.R.S., by encouraging divisions, departments and facilities owned, organized and/or operated by Health Systems to openly, honestly and effectively study and review the professional practice by and professional conduct of persons associated with or providing services in a division, department or facility of a Health System, including the professional review of the quality of service rendered by those members; and 3. Enable the Board to more effectively regulate the conduct of the practice of medicine by encouraging the prompt, accurate and complete reporting of instances of unprofessional conduct in the medical profession.

RULES AND REGULATIONS REGARDING THE DESIGNATION OF HEALTH SYSTEM AFFILIATIONS AND THE CORRESPONDING GRANT OF IMMUNITY In order to be designated a Health System Affiliation authorized to establish a professional review committee pursuant to Section 12-36.5-104(5), C.R.S., and entitled to the immunities provided by Section 12-36.5-101, et.seq. , C.R.S., such Health System Affiliation must comply with the following;

1. Each division, department and facility which is a part of the Health System shall ensure that all its employed, contracted or credentialed physicians are licensed to practice medicine in the State of Colorado.

2. A “Health System” is any corporation, partnership, limited liability company or other entity which owns and/or operates hospitals licensed in the State of Colorado, outpatient health care facilities and/or health clinics which provide medical services to individuals in the State of Colorado.

3. Divisions, departments and facilities owned and/or operated by a Health System may qualify as a “Health System Affiliation,” if it meets the following conditions:

1. a) The division, department or facility of a Health System shall offer and/or provide health care services.
2. b) The division, department or facility of a Health System shall establish and follow formal professional peer review processes for the purposes of furthering quality health care. A professional review committee of any Health System shall have jurisdiction to review only physicians and other health care providers who are employed, under contract with or credentialed by the division, department or facility of the Health System conducting the professional review.

4. Any professional review action taken by the Health System Affiliation which adversely affects, as defined in the Medical Staff documents of the division, department or facility of the Health System, the medical staff appointment and/or clinical privileges of a physician in the division, department or facility which constitutes a Health System Affiliation will be taken in conformity with state and federal law, including the procedures set forth in the Colorado Professional Review Statutes, Section 12-36.5-101, et.seq. , C.R.S., and 5. If, after the professional review committee has reported to the Board in accordance with Section 12- 36.5-104(7)(f), C.R.S., the Board determines, after initial review, consideration, or investigation, that the alleged conduct of the physician appointed to a Health System Affiliation conducting the professional review does not involve a violation of the provisions of the Colorado Medical Practice Act, Section 12-36-101, et.seq. , C.R.S., the reports of information submitted by the professional review committee of a Health System Affiliation and related documents or proceedings of the Board shall be confidential and not subject to public inspection or disclosure.

6. Records submitted to the Board by a peer review committee of a designated Health System Affiliation shall be entitled to protection against release or disclosure consistent with state and federal law. Effective: 12/30/97; Revised 08/19/10; Effective 10/15/10 _____________________________________________________ Editor’s Notes History Entire Rule eff. 10/15/2010.