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

Description

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