Contracted Services: Ensuring Compliance With CMS Hospital CoP Standards, TJC and DNV

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End Time:12:00 AM
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Provided by MHA Health Institute

Health Institute

Date & Time

Thursday, Aug. 29
9 - 11 a.m.

Register on or before Monday, Aug. 26, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Each additional phone line connection will be charged a registration fee. Get more value by inviting colleagues to join you on the one connection.

This webinar is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from the MHA Management Services Corporation.


C-Suite, contract management staff, accreditation and regulation personnel, risk and quality improvement managers/directors, TJC coordinators, nursing educators, credentialing committee members, compliance officers, hospital legal counsel, and others involved with contract services

The following program content was provided by the speaker.


Contracted services have been under scrutiny by The Joint Commission, Centers for Medicare & Medicaid Services and Det Norske Veritas Healthcare, including the reason CMS and TJC require hospitals to have a process in place to evaluate contracted services. The evaluation ensures staff compliance with the provisions included in the contract regulations, including standards with oversight from the hospital board. Whether the hospital uses its own employees or contractors, the hospital is liable for evaluating contracted services to ensure patients receive the highest quality care.

This webinar will cover the contract requirements for TJC-accredited hospitals and the CMS Hospital Conditions of Participation.


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

  • discuss the contract standard in TJC leadership chapter
  • discuss the section in the CMS hospital Conditions of Participation that sets forth requirements for contracted services
  • explain how the same level of care is required whether the hospital provides the services directly or through contracted services
  • identify the CMS requirement that explains how the board enures contract services are reviewed as part of the Quality Assurance Performance Improvement process
  • explain how hospitals accredited by DNV also must follow their contract management standards


Sue Dill Calloway, J.D., MSN, R.N.
Patient Safety and Healthcare Consulting and Education Company
Columbus, Ohio

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 and Consulting and previously was the chief learning officer for the Emergency Medicine Patient Safety Foundation.