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

Date :Monday December 09th, 2019

Location :Palo Alto
2479 East Bayshore Road,
Suite 200
94303 Palo Alto, United States

Type :Conference & Seminar - International audience

Accreditation :--


Further information


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.


  • 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


  • 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


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


Map and directions
Conference address :
Palo Alto
2479 East Bayshore Road,
Suite 200
94303 Palo Alto
United States
tel : +1-888-717-2436
Map and directions

Further information

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Contracted Services: Ensuring Compliance with the CMS Hospital CoP Standards, Joint Commission and DNV Hospital - Management - Nurses
cms, hospital, cop standards, joint commission, dnv, tjc, qapi, dnv-gl
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
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For more information on Contracted Services: Ensuring Compliance with the CMS Hospital CoP Standards, Joint Commission and DNV, plsase contactr ComplianceOnline

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