The Centers for Medicare and Medicaid
Services (CMS) hospital CoPs has sections on both board and medical
staff and includes information on credentialing and
privileging requirements; implementing Medical Staff (MS) bylaws
and rules and regulations; hospitals in systems; board
responsibility for quality and safety; sharing a board in hospital
systems; policy development; and history and physicals.
Many changes were made April of 2015
and some hospitals are still struggling to ensure compliance.
Therefore, the board and medical staff sections will be discussed in
detail. CMS allows a hospital system to share a medical staff;
CMS refers to this as a unified and integrated medical staff.
Boards must directly consult with an individual who is responsible for
the conduct of the medical staff at least twice a year. The medical
staff can credential the dietician to order diet and the registered
dietician can be a member of the medical staff or just credentialing
and privileging without being a member of the medical staff. Attendees
will learn more about these and other changes and updates for boards
and medical staff.
Sue Dill Calloway
President, Patient Safety and Health Care Education and
Sue Dill Calloway
has been a nurse attorney and consultant for more than 30 years.
Currently, she is president of Patient Safety and Healthcare Education
& Consulting. She was previously the chief learning officer for the
Emergency Medicine Patient Safety Foundation.
The speaker has no real
or perceived conflicts of interest that relate to this presentation.
At the conclusion of this session,
participants will be able to:
1. Discuss the CMS CoPs section related to
the Board and medical staff.
2. Describe how hospitals can have a
separate medical staff or a unified and shared integrated medical
3. Explain how CMS will allow the medical
staff to credential qualified dieticians to order the patient’s diet.