Hospital Management
CMS Regulatory Requirements For Emergency Preparedness Programs And TJC Compliance
The COVID-19 pandemic and multiple natural and man-made disasters over the past few years have required hospitals to activate their emergency preparedness plan. In anticipation of patient injury because of such disasters, CMS – Centers for Medicare and Medicaid Services – revised the Emergency Preparedness Conditions of Participation for hospitals in 2020. This webinar will cover CMS regulations for a..
Nurse To Nurse Bullying: A Sepsis In Healthcare
Nurse-to-nurse bullying threatens the safety and well-being of patients and nurses. The misconduct is a major problem for all nurses and causing 60% of new nurses to leave their first nursing position and 1 in 3 nurses to quit the profession. Sometimes the bullying is so subtle it is almost invisible yet causes cumulative damage to the targeted nurse as well as those nurses who witness the behavior. The Joi..
The Federal False Claims Act: Enforcement and Recent Updates
The session will provide an overview of the Federal Civil False Claims Act (FCA) and how it works. It will also provide an assessment of enforcement activities, showing how healthcare providers may be at risk. In addition, the session will review recent cases and show how they potentially impact healthcare providers.We will start with a review of the Federal False Claims Act and discuss how it works and how..
Grievances and Complaints: Ensuring Hospitals Compliance with the CMS CoPs, Joint Commission, DNV Standards and OCR
Hospitals that accept Medicare or Medicaid reimbursement must comply with the CMS Conditions of Participation. The CMS grievance requirements have been a frequent source of deficiency citations. The grievance standards for acute hospitals are in the patient rights section of the Conditions of Participation manual. Although there is no similar section for Critical Access Hospitals, and the requirements for a..
Implementing ISO 27799 - Information Security Management in Health Information
The session will begin with an overview of ISO 27799, its objectives, and its importance in the healthcare sector. Attendees will learn about aligning their existing security practices with ISO 27799 standards, thereby enhancing their overall information security posture. Emphasis will be placed on risk assessment, control measures, and continuous monitoring to identify and mitigate potential vulnerabilitie..
Stark After Tuomey, Intermountain Health, Akron General, Prime Healthcare and Kalispell Regional
The session will provide an overview of the physician anti-referral law (known as Stark II), and its available exceptions. It will also show how violation of Stark II can raise FCA concerns, and it will provide an assessment of enforcement activities, showing how participants may be at risk. In addition, the session will review recent cases and show how they potentially impact participants.Claims filed by h..
The CMS Hospital Infection Prevention and Control and Antibiotic Stewardship Program: CMS Compliance Requirements 2025
A hospital must have an active infection control program throughout the facility to track, prevent and control infectious diseases, including Healthcare Associated Infections, or HAIs. Additionally, the hospital must have a program for the optimization of antibiotic use through stewardship. This program will discuss the changes CMS made to the infection control standards in 2019, and the interpretive guidel..
Team Synergy: How to Harness Collective Intelligence to Maximize Individua Skills and Talents for Powerful Results
The speaker developed a model for team success and performance called Inner Quality Management. There are four facets of IQM:Internal Self-ManagementCoherent CommunicationBoosting Organizational ClimateStrategic Processes of RenewalHe worked with teams on four continents capturing best practices from the highest-performing teams.He observed the success of phenomenal sports teams like the Golden State Warrio..
Physician Employment Agreements: Problem Areas that can be Landmines
We will review the elements of the physician employment agreement that can cause the greatest problems, focusing on the pitfalls and the complications that can develop when the parties do not fully understand what is being agreed to. Such items as corporate practice, term and termination, termination for cause, duties of the physician, call, non-compete clauses, and compensation are all items that should be..
The Coherent Organization: Sustainable, Healthy, Compassionate, Effective
The Coherent Organization is based on a model for organizational performance developed by Bruce Cryer, called Inner Quality Management. There are four tenets of IQM, outlined in Bruce’s book, From Chaos to Coherence.Internal Self-ManagementCoherent CommunicationBoosting Organizational ClimateStrategic Processes of RenewalBruce worked with corporations, government agencies, health systems, and academic insti..
Informed Consent Update: Maneuvering the Maze Towards Compliance
Centers for Medicare and Medicaid (CMS) and the accrediting organizations, such as The Joint Commission (TJC) and DNV have certain elements required for informed consent. This program will discuss the current CMS hospital Conditions of Participation (CoPs), including critical access hospitals, Joint Commission and DNV Healthcare standards, on informed consent requirements. There are three different sections..
The Disruptive Practitioner: A Danger to the Hospital's Operation
Most disciplinary policies are progressive. A progressive policy applies increasingly more severe sanctions to additional incidents of bad behavior. It is very important that the organized medical staff have a disruptive practitioner policy. This webinar will discuss the development of such a policy, including what it should include, and how it should be implemented. It is also important to understand what ..
Medical Staff and Telemedicine: Meeting CMS Conditions of Participation and the Joint Commission Standards
Any hospital that accepts Medicare and Medicaid payments must comply with the regulations known as Conditions of Participation. The Centers for Medicare and Medicaid Services (CMS) hospitalCoPs have sections on all aspects of patient care including medical staff and telemedicine. The medical staff section includes information on credentialing and privileging requirements, implementing Medical Staff (MS) byl..
Paying for Referrals: A Danger to Your Freedom
The session will provide an overview of the Anti-Kickback Statute (AKS) and review what it prohibits, as well as review the Statute’s available safe harbors. It will also show how violation of the AKS can raise FCA concerns, and it will provide an assessment of enforcement activities, showing how participants may be at risk. In addition, the session will review recent cases and show how they potentially imp..
Complying with OCR Section 1557: Discrimination, Interpreters, Required Signs,and More
This webinar will discuss a law that applies to all hospitals, including critical access hospitals, and other healthcare providers such as physician offices and nursing homes. The law addresses nondiscrimination, required signs and notices, interpreters, a civil rights law for healthcare providers and others and more under Section 1557 of the Affordable Care Act. It forbids discrimination based on sex, race..