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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.
This program is timely because of the increase number of deficiencies received which are over 1,900. There are 2019 proposed changes under the transparency bill which will be discussed. This includes proposed changes to the history and physicals.
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 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 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.
|- Hospital system can share a board||- The Medical Staff composition|
|- Categories of practitioners eligible for appointment||- H&P|
|- Policy requirements and no system surveys||- Telemedicine requirements|
|- Board minutes of hospitals in systems||- Contract management|
|- MS by-laws and rules and regulations||- Care of patients|
|- MS accountability for the quality of care||- Emergency services|
|- Credentialing and privileging every two years||- Autopsies|
|- TJC contract services tracer||And more!|
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, Joint Commission coordinator, quality improvement staff, CNO, senior leadership team, patient safety officer, nurse educator, 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.
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