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.

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 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.

Online Registration

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.

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 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.

Objectives

· 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

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.

Fee

$185 per phone line connection