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Medical Staff and Telemedicine: Meeting CMS CoPs and TJC Standards (W4004)
This is a recording of a live webinar delivered on March 4, 2024.

Hospitals that accept Medicare and Medicaid payments must comply with the Conditions of Participation (CoPs). The Centers for Medicare & Medicaid Services (CMS) hospital CoPs have sections on all aspects of patient care, including medical staff and telemedicine. There are multiple deficiencies from CMS related to the medical staff section.  


This session will also cover the board and medical staff sections of the CoPs, and there will be a concurrent discussion of the Joint Commission (TJC) standards for medical staff.   


Although telemedicine has been a factor in health care for many years, COVID-19 gave it a larger role in the diagnosis and treatment of patients. This session will discuss standards for acute care hospitals, critical access hospitals, and rural emergency hospitals participating in telemedicine. Finally, this webinar will cover what provisions should be included in a telemedicine contract.    
Laura A. Dixon, BS, JD, RN, CPHRM
Picture of Laura Dixon

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.

This speaker has no real or perceived conflicts of interest that relate to this presentation.
Learning Objectives
At the conclusion of this session, participants should be able to:

  • Discuss that hospitals can have a separate medical staff or a unified shared integrated medical staff.
  • Describe the requirements for medical staff under the CMS Conditions of Participation and TJC standards.
  • Explain the requirement that hospitals must have a written telemedicine agreement specifying the responsibilities of the distant-site hospital and entities to meet the required credentialing requirements.
  • Recall that The Joint Commission has standards on telemedicine.
Continuing Education

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 Medical Staff and Telemedicine: Meeting CMS CoPs and TJC Standards 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.
Contact Us
Contact us at with any questions.
Availability: On-Demand
Cost: FREE
Credit Offered:
2 HLT Credits
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