CMS has issued many citations related to the Governing Board and specifically, contract management. This program will also discuss the standards for hospitals accredited by The Joint Commission and DNV which are closely crosswalked to the CMS CoPs.

The governing board of a hospital is responsible for oversight of contracted services and tips to ensure compliance will be discussed.  Hospitals must also have a process to evaluate the contracted services to ensure that the performance indicators are met and that compliance with the provisions contained in the contract regulations and standards with oversight from the Board.

This presentation will cover all the contract requirements for hospitals under the CMS Conditions of Participation and those accredited by the Joint Commission. This program will also cover the standards for hospitals accredited by DNV Healthcare.

• Describe CMS, Joint Commission, and DNV contract standards.
• Discuss that CMS has a section in the hospital conditions of participation that sets out requirements for contracted services.
• Explain that the same level of care is required whether the hospital provides the services directly or through contracted services.
• Recall that CMS requires that Board to make sure that contract services are reviewed as part of the QAPI process.

• Director of Accreditation and Regulation
• Hospital Attorneys
• Risk Managers
• Chief Nursing Officer
• Individuals responsible for contracted services
• C people (CEO, CFO, CNO, CMO)
• Quality improvement director
• Department directors
• Board members
• Credentialing committee members
• Medical staff services professionals
• Patient safety officer
• Compliance officer
• Nurse directors
• Joint Commission coordinator
• Regulatory department directors
• Nurse educators
• In house legal counsel
• Contract managers
• Patient safety officer
• Anyone responsible for monitoring or assessing contracted services such as department managers and directors