Governing Board and Contract Management: CMS, TJC and DNV Requirements

Webinar Details


Laura A Dixon






From: Apr 26, 2022 - To: Dec 31, 2022


120 Minutes

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CMS has issued many citations related to the Governing Board and contract management. This program will discuss the standards and responsibilities of the Governing Board and for hospitals under CMS Conditions of participation by The Joint Commission and DNV Healthcare standards related to contracts and governing board duties are very similar to the CMS CoPs.

The governing board of a hospital is responsible for the operation and management of the hospital. The C-suite, which includes the CEO, CNO, CMO, and CFO, is also involved with the operation of the hospital as they are tasked with ensuring implementation and safe provision of care within the hospital. Combined and separately, they have various responsibilities which are evaluated by CMS and the various accrediting organizations. 

Examples of some of the responsibilities include oversight of contracted services, ensuring there is a process to evaluate all services through QAPI, and ensuring performance indicators. Contract management has implications in compliance with CMS. 

This presentation will cover the requirements for the Governing Board and C-Suite of hospitals under the CMS Conditions of Participation and those accredited by the Joint Commission and DNV Healthcare.

Learning Objectives

  • Describe CMS, Joint Commission, and DNV standards for Governing Board and contract management.
  • Explain that the Governing Board is responsible for the operation of, and provision of care by the hospital.
  • Explain that C-Suite management is responsible to the Governing Board for the implementation of policies and procedures and provision of safe care.
  • Recall that CMS requires that Board ensures all services, including contracted services, are reviewed as part of the QAPI process.

Who Should Attend

  • Governing Board members
  • C-Suite (CEO, CFO, CNO, CMO)
  • Director of Accreditation and Regulation
  • Hospital Attorneys
  • Risk Managers
  • Individuals responsible for contracted services
  • Quality improvement director
  • Department directors
  • Patient safety officer
  • Compliance officer
  • Joint Commission coordinator
  • Regulatory department directors
Laura A Dixon
Laura A Dixon


Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners, and staff in multiple states. Such services included the creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes representation of clients for Social Security Disability Insurance providing legal counsel and representation at disability hearings and appeals, medical malpractice defense, and representation of nurses before the Colorado Board of Nursing. As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.