CMS has issued many citations related to the Governing Board and contract management. This program will discuss the standards and responsibilities of the Governing Board and for hospitals under CMS Conditions of participation by The Joint Commission and DNV Healthcare standards related to contracts and governing board duties are very similar to the CMS CoPs.

The governing board of a hospital is responsible for the operation and management of the hospital. The C-suite, which includes the CEO, CNO, CMO, and CFO, is also involved with the operation of the hospital as they are tasked with ensuring the implementation and safe provision of care within the hospital. Combined and separately, they have various responsibilities which are evaluated by CMS and the various accrediting organizations. 

Examples of some of the responsibilities include oversight of contracted services, ensuring there is a process to evaluate all services through QAPI, and ensuring performance indicators. Contract management has implications in compliance with CMS. 

This presentation will cover the requirements for the Governing Board and C-Suite of hospitals under the CMS Conditions of Participation and those accredited by the Joint Commission and DNV Healthcare.

Learning Objectives:-

• Describe CMS, Joint Commission, and DNV standards for Governing Board and contract management.
• Explain that the Governing Board is responsible for the operation of, and provision of care by the hospital.
• Explain that C-Suite management is responsible to the Governing Board for the implementation of policies and procedures and provision of safe care.
• Recall that CMS requires that Board ensures all services, including contracted services, are reviewed as part of the QAPI process.

Who Should Attend:-

• Governing Board members
• C-Suite (CEO, CFO, CNO, CMO)
• Director of Accreditation and Regulation
• Hospital Attorneys
• Risk Managers
• Individuals responsible for contracted services
• Quality improvement director
• Department directors
• Patient safety officer
• Compliance officer
• Joint Commission coordinator
• Regulatory department directors