CMS Tells Contractors It May Rethink New Hospital Conditions of Participation

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By Nathaniel Weixel  

The Centers for Medicare & Medicaid Services June 15 said it will hold off implementing a new requirement that hospital governing boards include a medical staff member and will reconsider the requirement in future rulemaking.

In a memo to state Medicare survey agencies, the agency said it is “presently reconsidering this policy in light of the numerous comments that have been received since publication of the final rule.”

The new rule seemed to pit the competing interests of hospitals and physicians against each other, as negative comments came from hospital stakeholder groups like the American Hospital Association, while the American Medical Association, a physician group, urged CMS to keep the revisions.

AHA specifically called on CMS to rescind the rule, saying in a letter June 5 the policy changes violated the Administrative Procedure Act and represented “a surprising and impermissible about-face” from the proposed rule released in October 2011 (111 HCDR, 6/11/12).

AHA also noted that, although many hospitals have a member of their medical staff on their governing board, others--for important reasons--do not, and, in some cases, by law, cannot.

Effective Date in Jeopardy.

CMS in May adopted several changes to the hospital conditions of participation, including the requirement to include a member of the medical staff on the hospital's governing board, as well as a reinterpretation of the existing medical staff provision to prohibit a health system from having a single, integrated medical staff that serves more than one hospital.

CMS said surveyors should not assess compliance with the governance requirement or cite related deficiencies without receiving instructions from the agency.  


CMS in the memo said it is in the process of developing detailed “interpretive guidelines” to assist surveyors in assessing compliance under the revised regulations.

However, the agency said that “due to the number and complexity of the revisions,” the guidance “may not be published for all of the affected requirements by July 16th, the effective date of the final regulations.”

CMS said surveyors should not assess compliance with the governance requirement or cite related deficiencies without receiving instructions from the agency. In addition, the agency said CMS-approved hospital accreditation programs are not expected to revise standards or survey processes related to the requirement “until we have addressed the issue completely.”

Doctors Wanted Policy to Stay.

Despite the negative reaction from hospitals, the American Medical Association had urged CMS to resist calls to rescind the rule (116 HCDR, 6/18/12).

Only a week after AHA sent its letter to CMS, AMA told the agency its decision to require medical staff representation on a hospital's governing board “is absolutely essential to the delivery of quality care.”

The medical staff and the governing board share responsibility for patient safety and quality of care, AMA said. Although business executives, attorneys, and civic leaders who normally sit on these boards bring considerable expertise to managing a hospital, only physicians are “equipped to evaluate and guide patient care at the facility,” AMA said.

CMS's requirement, the association said, “will promote greater coordination between the [medical staff and the board] and further inform patient health and safety initiatives within the hospital.”

By Nathaniel Weixel  

The CMS memo is at

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