CMS Governing Board and Contract Management (W6014)-CMS Governing Board and Contract Management Recording

Video Transcription

Video Summary

Laura Dixon, a nurse-attorney and former risk management and patient safety leader, presents an overview of CMS requirements for hospital governing boards and how boards must manage contracted services. She explains that the governing body is legally responsible for everything that occurs in a hospital—medical staff appointment and privileging, policy approval, quality oversight, and compliance with all Conditions of Participation (CoPs). Survey deficiencies commonly tied to board failure include allowing clinicians to practice outside privileges, not enforcing policies/bylaws, inadequate resources for emergency/surgical services, poor infection control and QAPI oversight, lack of staff training, and leadership gaps (e.g., no interim CEO).<br /><br />Key governance requirements include maintaining an effective board (or documented responsible individual), clarifying actions when one board oversees multiple hospitals, and ensuring each hospital adopts system policies separately. Boards must oversee medical staff structure, credentialing/privileging based on defined criteria (character, competence, training, experience, judgment), approve medical staff bylaws and revisions, and consult directly with medical staff leadership at least periodically (CMS suggests twice yearly), with synchronous communication allowed.<br /><br />She reviews patient-care accountability rules, including physician responsibility for Medicare patients and limited exceptions for nurse midwives with Medicaid, plus telemedicine credentialing via written agreements and reporting of adverse events to the distant site.<br /><br />Contract management is emphasized: boards remain responsible for contracted services (clinical and support), must keep a centralized contract list/log, set performance metrics, evaluate contractors through QAPI, ensure staff licensure/orientation/competency, and include contract provisions for compliance, reporting, insurance/indemnification, and termination when patient safety is at risk. New OB services CoPs (2025–2027) require organized staffing, standards-based care, and mandated training tied to QAPI.

Keywords

CMS hospital governing board requirements

Conditions of Participation (CoPs) compliance

hospital board legal accountability

medical staff appointment and privileging

credentialing and privileging criteria

medical staff bylaws approval and enforcement

quality assessment and performance improvement (QAPI) oversight

infection control governance deficiencies

contracted services oversight and accountability

centralized contract log and performance metrics

telemedicine credentialing by proxy agreements

new obstetric services CoPs 2025–2027