Health Care: CMS Changes Impact Hospital Governing Body and Medical Staff (5/14)


Governing Body Consultation with Medical Staff Leaders

The Center for Medicare/Medicaid Services (CMS) has pulled back on its recent mandate that a medical staff member serve on a hospital governing board. In lieu of this, CMS now requires that a hospital’s governing body directly consult with the individual who is responsible for the organization and conduct of the hospital’s medical staff or his/her designee (e.g., the medical staff president) periodically throughout the year. This consultation is required to be meaningful and include a discussion regarding the quality of patient care provided by the hospital. If the governing body has authority over more than one hospital, the consultation may be with more than one medical staff leader and must ensure that the unique needs of each hospital and its patients are recognized.

CMS Permits Integrated Medical Staff for Hospital System

In a "reinterpretation" of an existing rule governing hospital medical staffs, CMS now permits separately certified hospitals, as members of a multi-hospital system, to share a unified and integrated medical staff. While the new interpretation of the rule permits medical staffs to be combined, it also requires that medical staffs be capable of opting out of such combinations. Given this instruction, multi-hospital systems need to present this option to the medical staff members for consideration.

There are four requirements to demonstrate that the requirements of this rule are met:

  • The distinct hospital(s) must be part of a hospital system.
  • A majority of the voting members of the medical staff at each hospital in the system must vote to either accept a unified and integrated medical staff structure or to opt out of such structure and maintain hospital-specific separate and distinct medical staffs.
  • If a unified and integrated medical staff is established, it must have bylaws, rules and other requirements describing self-governance, appointment, credentialing and privileging, oversight, peer review policies and due process rights which are guaranteed to the medical staff. There must also be a demonstrated process whereby the voting members of each separately certified hospital are advised of their right to opt out and to return to a separate and distinct medical staff by a majority vote of the members.
  • A unified medical staff must take into account each member hospital’s unique circumstances and significant differences in patient populations and services offered at each hospital. The needs and concerns of the medical staff must be given due consideration regardless of which hospital they practice in and a mechanism to ensure that localized issues of each hospital are duly considered and addressed.



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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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