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.
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.