CMS updates hospital conditions of participation for the medical staff and governing body


The start of a shiftOn May 12, 2014, the Centers for Medicare & Medicaid Services (“CMS”) published a final rule updating the hospital conditions of participation related to the medical staff and the governing body (“Final Rule”). Specifically, the Final Rule addresses (1) the composition of the medical staff and governing body, (2) required consultation between the governing body and medical staff, and (3) requirements for a unified and integrated medical staff for multi-hospital systems. We’ve summarized some of the highlights below.

Composition of medical staff and governing body

CMS clarified the requirement that a hospital’s medical staff must be composed of doctors of medicine or osteopathy and also stated that the medical staff may include, in accordance with state law, (1) other categories of providers (e.g., dentists, podiatrists, optometrists, chiropractors, and clinical psychologists), and (2) non-physician practitioners who are determined eligible for appointment by the hospital’s governing body (e.g., advanced practice registered nurses, physician assistants, registered dieticians, and doctors of pharmacy). In addition, CMS removed the requirement that a member of the hospital’s medical staff be on the hospital’s governing body.

Consultation between governing body and medical staff

CMS added a new provision requiring the hospital’s governing body to directly consult periodically with the individual responsible for the organized medical staff of the hospital. If a multi-hospital system uses a single governing body to oversee multiple hospitals, that single governing body must consult directly with the individual responsible for each hospital’s organized medical staff within the multi-hospital system.

Unified and integrated medical staff of multi-hospital systems

CMS reinterpreted the regulation regarding the medical staff of multi-hospital systems. Under the Final Rule, a unified and integrated medical staff may be shared by multi-hospital systems if the following requirements are satisfied:

  • The medical staff members must vote to participate in the unified and integrated medical staff or vote to opt-out and maintain a hospital-specific separate and distinct medical staff.
  • The medical staff bylaws, rules and regulations must provide that the medical staff members have the right by majority vote to opt-out of the unified and integrated medical staff structure and maintain a separate and distinct medical staff for their hospital. 
  • The unified and integrated medical staff must be established in a manner that takes into account each hospital’s unique circumstances and any significant differences in patient populations and services offered in each hospital.
  • The unified and integrated medical staff must give due consideration to the needs and concerns of medical staff members, regardless of practice or location, and ensure that issues specific to each hospital are duly considered and addressed. 

While these provisions mainly provide multi-hospital systems more flexibility in setting up their medical staff and governing body, hospital systems are advised to carefully consider and understand the specifics of the Final Rule before implementing these changes. The Final Rule can be accessed here.




DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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