CMS Governing Board and Contract Management (W5015)-Governing Board and Contract Management Presentation

Governing Board and Contract Management Presentation

Pdf Summary

The document is a comprehensive guide on ensuring hospital compliance with Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, focusing on governance and contractual management. It highlights the responsibilities of hospital governing boards and provides insights into reasons hospitals might be cited for deficiencies. Key areas of concern include failing to adhere to medical staff bylaws, improper training for handling violent patients, medication errors, and appointment of interim CEOs and nursing supervisors.<br /><br />Hospital governing bodies are responsible for the hospital's operation and must legally oversee its functions. They need to establish bylaws, ensure quality care, and have clear policies regarding medical staff appointments. The CMS expects governing boards to engage in regular consultation with medical staff to maintain healthcare quality.<br /><br />Contract management is another critical component, where hospitals must ensure all contracted services meet regulatory standards and address specific performance indicators. Contractual services include clinical care, laundry, security, and more. Hospitals must maintain an updated list of contracts, ensuring each service adheres to CMS regulations. Additionally, the CMS advises hospitals to adopt telemedicine services through structured agreements, ensuring patient care meets standardized quality regardless of where it originates.<br /><br />The document also discusses how hospital systems must operate under centralized, consistent regulations even when sharing boards across multiple hospitals or states. Each hospital within a system must personally adopt system policies to comply with the CMS's requirements.<br /><br />Critical Access Hospitals, a distinct category, must similarly comply with CMS guidelines. They can contract services but must verify every contracted service's legitimacy and quality, including laboratory and radiology services.<br /><br />Finally, the document provides a series of contract management guidelines, from maintaining a comprehensive contract log to ensuring contracts contain performance-based metrics and expectations. This extensive outline serves as a guide for healthcare administrators and legal experts to align their operations with CMS standards, ensuring compliant, safe, and high-quality patient care.

Keywords

CMS Conditions of Participation

hospital compliance

governance

contractual management

medical staff bylaws

contract management

telemedicine services

Critical Access Hospitals

performance metrics

healthcare quality