Medical Staff, Telemedicine and Other Changes: Meeting CMS Conditions of Participation and TJC Standards

Medical Staff, Telemedicine and Other Changes: Meeting CMS Conditions of Participation and TJC Standards

  LAURA A DIXON

  Director

Department of Patient Safety

  Product ID : DIXO-0001

  Level : Intermediate

  Duration : 90 Minutes


Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners, and staff in multiple states. Such services included the creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

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

Ms. Dixon’s legal experience includes medical malpractice defense and representation of nurses before the Colorado Board of Nursing. As a registered nurse and attorney, Laura 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 Centers for Medicare and Medicaid Services (CMS) hospital CoPs has a section on the medical staff. It includes information on credentialing and privileging requirements, implementing Medical Staff (MS) bylaws and rules and regulations, hospitals in systems. This webinar will also cover the Joint Commission standard for medical staff, plus telemedicine and the federal regulations under CMS associated with telemedicine.

Areas Covered

  • Appointment of individuals to the MS
  • MS by-laws and rules and regulations
  • MS accountability for the quality of care
  • Credentialing and privileging frequency
  • Separate medical staff or unified shared integrated medical staff
  • The Medical Staff composition
  • Medical staff duties in credentialing all eligible candidates for medical staff membership and make recommendations to the board
  • H&P revised rules
  • Care of patients
  • Emergency services
  • Autopsies and changes in 2020
  • TJC Standards for Medical Staff
  • Telemedicine requirements
  • CMS deficiencies in telemedicine for hospitals
  • Definitions of distant site telemedicine entity (DTSE)
  • Requirement for and in the written agreement for Telemedicine
  • Telemedicine privileges based on medical staff recommendations
  • Credentialing by proxy
  • Agreements with Medicare-certified hospitals
  • Agreements with DTSE
  • Effect on Joint Commission hospitals
  • Reliance on the C&P decisions of the distant site
  • Peer review issues
  • Adverse events and notification
  • Periodic appraisals
  • Complaints received about the distant site physician
  • Third-party verification organization

Course Level - Intermediate

Who Should Attend

  • Chief Medical Officer
  • Medical Staff leader
  • Credentialing and Privileging Professionals
  • Physicians
  • Medical staff office staff and coordinator
  • Teleradiology Professionals
  • Chief Nursing Officer
  • Chief Operating Officer
  • Director of Radiology
  • Director of Pharmacy
  • Hospital legal counsel
  • Risk manager
  • Compliance officer – CMS and/or TJC/DNV
  • Joint Commission director
  • Accreditation Director
  • Director of Regulatory Affairs
  • Telemedicine director
  • Anyone involved or in contracting for telemedicine services
  • Health information management officer

Why Should You Attend

Changes to CMS regulations affecting medical staff. Changes also reflected by Joint Commission. CMS issued over 2,180 deficiencies and/citations related to the Medical Staff section. All hospitals that accept Medicare/Medicaid payments must comply with all sections of the CMS State Operations Manual which includes Medical Staff.

  • $200.00


Recorded / Download Access