Understanding Hospital Board and Medical Staff Responsibilities under Medicare Conditions of Participation

Overview:

Over the last several years, there has been increasing scrutiny by regulators and accrediting organizations on the hospital’s governing body role in the hospital’s compliance with Conditions of Participation. This presentation will examine situations where the governing body will be cited due to Condition Level deficiencies. This presentation will also review the Medical Staff rules and regulations with emphasis on appropriate medical staff credentialing.

Objectives:

• Describe overall governing board responsibilities and specific responsibilities relating to patient rights, quality improvement and medical staff credentialing
• Describe minimum requirements for medical staff bylaws, rules and regulations
• Explain the differences in medical staff credentialing regulations for telemedicine providers and onsite providers
• Describe hospital responsibilities for credentialing of non-physician staff in the OR

CE’s: NHA

Presenter:

Nancy Ruzicka, Owner/Consultant, Ruzicka Consulting

Nancy Ruzicka has experience teaching and assisting hospitals and other healthcare facilities in understanding applicable Federal and State laws, rules, regulations and interpretative guidelines. Her experience also encompasses teaching all levels of healthcare staff in understanding compliance and HIPAA requirements. Nancy has been a frequent speaker for the Iowa Hospital Association on EMTALA and Conditions of Participation for hospitals and critical access hospitals.

Nancy’s previous experiences include Director of Integrity & Compliance and Privacy Official at Mercy Medical Center, Des Moines; Director of Regulatory Compliance at UnityPoint Health and over twenty years of experience with Iowa Department of Inspections and Appeals. Nancy received her MJ in Health Law, MBA and BS in Pharmacy from Drake University, Des Moines. She is certified in Healthcare Compliance (CHC) and maintains her Iowa pharmacy license.