Medical Staff: Complying with the CMS Hospital CoPs

Webinar Details

Speaker

Laura A Dixon

Industry

Nursing

Speciality

Nursing

Available

All Days

Duration

120 Minutes


Registration Options

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Description

The Centers for Medicare and Medicaid Services (CMS) hospital CoPs have a section on the medical staff. This includes information on credentialing and privileging requirements, implementing Medical Staff (MS) bylaws and rules and regulations, hospitals in systems.

This program is timely because of the increased 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.

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. 

The Medical Staff can credential the dietician to order the 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.

There will also be a concurrent discussion of TJC standards for medical staff.

Learning Objectives

  • Discuss that CMS has a section related to the 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
  • Describe the requirements for a medical staff under TJC standards

Outline

  • Policy requirements and no system surveys
  • Three new laws for 2020; autopsies, H&P, and infection control
  • Appointment of individuals to the MS
    • On the advice of MS
  • MS by-laws and rules and regulations
  • MS accountability for the quality of care
  • Credentialing and privileging every two years
  • Separate medical staff or unified shared integrated medical staff
  • The Medical Staff composition
  • The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the board.
  • The Medical Staff can also include non-physicians such as APNs. PAs, registered dieticians, doctors of pharmacy, etc.
  • Qualified dieticians and qualified nutrition specialists may be credentialed and privileged to write orders for a diet that includes a therapeutic diet, supplements, and enteral nutrition
  • H&P revised rules
  • Telemedicine requirements
  • Care of patients
  • Emergency services
  • Autopsies and changes in 2020
  • TJC Standards for Medical Staff

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.

Laura A Dixon
Laura A Dixon

(BS, JD, RN, CPHRM)

Laura Dixon | Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, of 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 consultation and training to facilities, practitioners, and staff in multiple states. Such services included the creation of presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to joining COPIC, she served as the Director, of the 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 in the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

Ms. Laura Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.

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.

Registration Options

Choose Your Options

Save $10 - [ HEALTHCPTI ]

Error Conference Exists In Wish-list.

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Need Corporate Discount ?


  • * For more than 6 attendee call us at +1-800-803-7592 or mail us at cs@conferencepanel.com
  • * For Check and ACH payment call us at +1-800-803-7592 or mail us at cs@conferencepanel.com
  • * Click to download the Order Form
Laura A Dixon
Laura A Dixon

(BS, JD, RN, CPHRM)

Laura Dixon | Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, of 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 consultation and training to facilities, practitioners, and staff in multiple states. Such services included the creation of presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to joining COPIC, she served as the Director, of the 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 in the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

Ms. Laura Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.

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.