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Boards and Medical Staff; Complying with the CMS Hospital CoPs and New Changes

Recorded Session | Sue Dill Calloway | From: Oct 08, 2020 - To: Dec 31, 2020
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Course Description

The Centers for Medicare and Medicaid Services (CMS) hospital CoPs have a section on both board and medical staff. This includes information on credentialing and privileging requirements, implementing Medical Staff (MS) bylaws and rules and regulations, hospitals in systems, board responsibility for quality and safety, sharing board in hospital systems, policy development, history and physicals, and more. It includes contract management requirements, budget, and emergency services.

This program is timely because of the increasing number of deficiencies received which are over 2,180. There are three significant changes that became effective November 29, 2019, to the CoPs under the transparency bill, discharge planning, and hospital improvement rule which will be discussed. This includes changes to the history and physicals for healthy patients having outpatient procedures and changes to the autopsy rules. It also requires the board’s involvement and responsibility if the hospital decides to do system-wide QAPI or infection control. The board must also appoint the infection preventionist after approval of the Medical Executive Committee and nursing leadership. CMS has a new website to get the CMS manuals and a new email to ask questions and these will be provided.

Many changes were made in April of 2015 and some hospitals are still struggling to ensure compliance. CMS allows a hospital system to share a medical staff that CMS refers to as a unified and integrated medical staff.  Boards must directly consult with an individual who is responsible for the conduct of the medical staff at least twice a year.

The Medical Staff can credential the dietician to order diet and the RD can be a member of the medical staff or just C&P without being a member of the Medical Staff. The board and Medical Staff sections will be discussed in detail.


  • Discuss that CMS has a section related to the board and medical staff in the hospital CoPs
  • Describe that hospitals can have a separate medical staff or a unified shared integrated medical staff
  • Recall that CMS will allow the Medical Staff to credential qualified dieticians to order the patient’s diet if state law allows
  • Describe what are the  contract management requirements


  • Board required and legally responsible for the conduct of the hospital
  • Hospital system can share aboard
  • Board required to ensure medical staff  (MS) requirements are met
    • Categories of practitioners eligible for appointment
  • Policy requirements and no system surveys
  • Three new laws for 2020; autopsies, H&P and infection control
  • Board responsibility for system-wide QAPI and infection control
  • Board must appoint infection preventionist
  • Board minutes of hospitals in systems
  • Appointment of individuals to the MS
    • On advise of MS
  • MS by-laws and rules and regulations
  • MS accountability for the quality of care
  • Credentialing and privileging every two years
  • Separate medical staff or unified shared integrated medical staff
  • The board must consult with CMO or president of MS at least twice a year
  • The Medical Staff composition
  • The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the board.
  • The Medical Staff can also include non-physicians such as APNs. PAs, registered dieticians, doctors of pharmacy, etc.
  • Qualified dieticians and qualified nutrition specialist may be credentialed and privileged to write orders for the diet which includes therapeutic diet, supplements, and enteral nutrition
  • H&P revised rules
  • Telemedicine requirements
  • Contract management
  • Plan and budget
  • Care of patients
  • Emergency services
  • Autopsies and changes in 2020

Who Should Attend?

This program is designed for anyone who is involved in understanding and complying with both the CMS Hospital Conditions of Participation on board and Medical Staff requirements. This includes President of the Medical Staff, chief medical officer, Board Members, Physicians, Medical Staff Office staff,  medical staff coordinator, Regulatory compliance, Compliance Officer, Director Joint Commission Coordinator, Quality Improvement staff, Chief Nursing Officer, Chief Operating Officer, senior leadership team, patient safety officer, nurse educator, nursing department managers and directors, health information management director and staff, pharmacist, nurse managers, nurses, policy and procedure committee, risk managers, Dietician, Radiology Director, hospital legal counsel, Outpatient Director, Pharmacist Director, and staff nurses should also attend.