Contracted Services: Ensuring Compliance with the CMS Hospital CoP Standards, Joint Commission and DNV


Instructor: Sue Dill Calloway
Product ID: 705555

  • Duration: 120 Min
This webinar will cover all of the contract requirements for hospitals accredited by the Joint Commission. This standard has been amended every year for the past three years. The CMS telemedicine standard also updated a section in the Joint Commission contract standards.
Last Recorded Date: Jan-2018


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Why Should You Attend:

This presentation will cover all of the contract requirements for hospitals accredited by the Joint Commission. This standard was amended every year for the past three years. The CMS telemedicine standard also updated a section in the Joint Commission contract standards. It is covered in the TJC contract tracer. This program will also cover the standards for hospitals accredited by DNV-GL.

The webinar will include the CMS hospital condition of participation requirements for contracts. Every hospital that accepts Medicare or Medicaid reimbursement must follow the CMS contract regulations and interpretive guidelines. The board will have to have a contract with the telemedicine facility that they are using for teleradiology and telecommunication and this program will talk about what must be in the contract.

CMS has added a section to the final CMS worksheets to ensure the surveyors addresses the contract management issue.

Learning Objectives:

Upon completion of this program, participants will be able to:

  • Recall that The Joint Commission has a contract standard in the leadership chapter
  • Discuss that CMS has a section in the hospital conditions of participation that sets forth requirements for contracted services
  • Describe that the same level of care is required whether the hospital provides the services directly or through contracted service
  • Recall that CMS requires that board to make sure that contract services are reviewed as part of the Quality Assurance & Performance Improvement (QAPI) process
  • Discuss that hospitals accredited by DNV must also follow their contract management standards

Areas Covered in the Webinar:

  • The Joint Commission standards LD.04.03.09
    • Contract standard and the EPs
    • Same level of care
    • Updates
    • Hospital leader responsibility for contracted services
    • Safety and quality requirements
    • Limited applicability to patient care services
    • Consults and referrals not subject to requirements
    • Staff competence
    • Credentialing/privileging and CMS interpretive guidelines
    • Transmittal issued
    • CMS changes on telemedicine
    • Performance improvement requirements
    • Ideas on how to review contracts
    • Credentialing and privileging
    • Nature and scope of services
    • Leadership approval of contracts
    • Monitoring the performance of contracts
    • Contracts with other accredited organizations
    • Communicating expectations in writing
    • Contracts that do not meet expectations
    • Continuity of patient care maintained if contract terminated
    • Contract lab services
    • 3 FAQs
    • Telemedicine contracts
    • TJC contract services tracer
  • CMS Contract Regulations and Interpretive Requirements
    • Introduction into CoPs
    • CMS deficiency memos and areas in contract management cited
    • How to locate current copy
    • Contract part of CMS hospital worksheet
    • List of contracted services required
    • CMS contract section in worksheets
    • Board responsible for contracted services
    • Board action to identify quality problems
    • Performance improvement requirements
    • Final CMS Work sheet and Contract requirement
  • DNV-GL Standards on Contract Management
    • Measurement, monitoring and analysis
    • Board legal responsibilities for contracts
    • Contracted services requirements
    • Ensuring contracts are safe and effective
    • Telemedicine contracts
    • List of contracts required

Who Will Benefit:

  • Director of Accreditation and Regulation
  • Hospital Attorneys
  • Risk Managers
  • Chief Nursing Officer
  • Individuals responsible for contracted services
  • C people (CEO, CFO, CNO, CMO)
  • Quality improvement director
  • Department directors
  • Board members
  • Credentialing committee members
  • Medical staff services professionals
  • Patient safety officer
  • Compliance officer
  • Nurse directors
  • Joint Commission coordinator
  • Regulatory department directors
  • Nurse educators
  • In house legal counsel
  • Contract managers
  • Patient safety officer
  • Anyone responsible for monitoring or assessing contracted services such as department managers and directors
Instructor Profile:
Sue Dill Calloway

Sue Dill Calloway
chief learning officer, Emergency Medicine Patient Safety Foundation

Sue Dill Calloway is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. She was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer.

Ms. Calloway has done many educational programs for nurses, physicians, and other health care providers. She has authored over 102 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.

Topic Background:

Contracts have become a recent hot topic with increased scrutiny by both the Joint Commission and CMS. Joint Commission has both a standard on contract managements and a contract services tracer. CMS recently issued a memo summarizing deficiencies received by hospitals and there were many related to contract management which will be discussed. This program will also discuss the standards for hospitals accredited by DNV-GL which are closely cross- walked to the CMS CoPs.

Hospitals have been asked why they have contracted with certain entities. Hospitals must also have a process to evaluate the contracted services. The evaluation needs to ensure compliance with the provisions contained in the contract regulations and standards with oversight from the Board. The bottom line is whether the hospital uses its own employees or contracts out the service with contracted employees, the hospital must still evaluate the service and ensure patients are still getting good quality of care. The board is responsible for oversight of contracted services and tips to ensure compliance will be discussed.

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