Governing Board and Contract Management: CMS, TJC and DNV Requirements (W4014)
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Credit Offered
1 HLT Credit
This is a recording of a live webinar delivered on May 7, 2024.


The Centers for Medicare & Medicaid Services (CMS) has issued many citations related to the governing board, specifically contract management. The governing board of a hospital oversees contracted services and ensures compliance with standards set forth by accrediting bodies. This presentation will cover all contract requirements for hospitals under the CMS Conditions of Participation and those accredited by the Joint Commission and DNV-GL.

Laura A. Dixon, BS, JD, RN, CPHRM 

Laura A. Dixon served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the director, facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. 

Dixon has more than 20 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 in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States  

As a registered nurse and attorney, Dixon 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.

The speaker has no real or perceived conflicts of interest that relate to this presentation.

At the conclusion of this session, participants should be able to: 


  • Describe CMS, Joint Commission and DNV standards for the governing board and contract management.
  • Explain that the governing board is responsible for the hospital’s operation and provision of care.
  • Discuss that the C-suite is responsible to the governing board for implementation of hospital policies and procedures.
  • Recall that CMS requires the governing board to ensure all services, including contracted services, are reviewed as part of the QAPI process.

The Georgia Hospital Association Research & Education Foundation is an approved provider of nursing home administrator credits as a professional trade association in long term care under Ga. Comp. R. & Regs. 393-13-.02, (1) (a). Approved for 2 contact hours. 

By attending Governing Board and Contract Management: CMS, TJC and DNV Requirements offered by Georgia Hospital Association, participants may earn up to 2 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Attendees who wish to have the hours applied toward ACHE Qualifying Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualifying Education Credit.  

Please complete the course evaluation to earn your certificate of participation.
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