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

Product Id : HE276
Instructor : Sue Dill Calloway
May 18, 2020 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

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The Centers for Medicare and Medicaid Services (CMS) hospital CoPs has 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 a 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 increase number of deficiencies received which are over 2,180. There are three significant changes that became effective on 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 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 but some hospitals are still struggling to ensure compliance. CMS allows a hospital system to share a medical staff which 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 dietitian 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.

Session Highlights:

  • 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
  • Describe what are the contract management requirements

Who Should Attend?

  • Chief Medical Officer
  • Chief Operating Officer
  • Board Members
  • Physicians
  • Medical Staff and Coordinator
  • Legal and Compliance Officer
  • Director Joint Commission Coordinator
  • Quality Improvement Staff
  • Chief Nursing Officer, Nurse Educator, Nursing Department Managers and Directors, Nurse Managers and Nurses.
  • Risk Managers
Speaker Profile:

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of legal services at a community hospital in addition to being the privacy officer and the compliance officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well-known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.

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