Medical Staff and Telemedicine: Meeting CMS Conditions of Participation and The Joint Commission Standards

Audience

CNOs, CMOs, compliance officers, TJC coordinators, risk managers, legal counsel, emergency department personnel, medical records personnel and quality improvement personnel

The following program content was provided by the speaker.

Overview

There are more than 800 deficiencies from the Centers for Medicare & Medicaid Services related to the medical staff section of the CMS Conditions of Participation manual. A significant change to the CoPs under the Transparency Rule includes revisions to the history and physicals for healthy patients having outpatient procedures. Additionally, updates were made to autopsy rules and will be discussed in this program.

CMS allows a hospital system to share a medical staff, which CMS refers to as a unified and integrated medical staff. The board and medical staff sections will be reviewed in detail during this session. There also will be a concurrent discussion of The Joint Commission 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. With the expanded use, the federal government, some states and health insurers quickly suspended regulations that limited telemedicine. Telemedicine continues to be a significant factor in health care today. Every hospital and critical access hospital performing telemedicine should ensure compliance. Standards for both will be discussed.

A problematic standard regarding telemedicine is the failure of the hospital to have the required sections in the contract for telemedicine services. This virtual event will cover what provisions need to be followed in the telemedicine contract.

Objectives

• • recall that hospitals can have a separate medical staff or a unified, shared and integrated medical staff
  • describe the requirements for a medical staff under CMS Conditions of Participation and TJC standards
  • discuss the requirement that hospitals must have a written agreement that specifies the responsibilities of the distant-site hospital and entities to meet the required credentialing requirements
  • recall that TJC has standards on telemedicine

Faculty

Lena Browning, MHA, BSN, RNC-NIC, CSHA
Nash Healthcare Consulting

Lena Browning is a nurse leader and accreditation specialist with more than 25 years of experience in clinical leadership in acute care settings. As a principal consultant with Compass Clinical Consulting, Browning served as team lead for the accreditation and regulatory compliance survey team. Most recently, Browning has fulfilled three interim positions as director of accreditation and was responsible for restructuring accreditation departments and leading organizations in compliance. Additionally, Browning has successfully coached numerous organizations through Immediate Jeopardy situations with all organizations getting the Immediate Jeopardy lifted and no condition-level findings noted on return surveys.

Prior to consulting, Browning had over two decades of experience in accreditation and regulatory leadership. As an expert for CMS, TJC, and state regulations, she has performed system-wide tracers for continuous readiness and patient safety, coordinated accreditation and regulatory surveys, chaired continuous readiness committees, and coached staff and leadership in compliance and performance improvement strategies.

Browning earned a Master of Healthcare Administration from the University of Southern Indiana and a Bachelor of Science in Nursing from Murray State University. She holds numerous certifications in basic life support, neonatal and pediatric advanced life support, and newborn resuscitation and post-resuscitation stabilization. She also is a member of the Association for Professionals in Infection Control and Epidemiology.