Synergy - July/August 2014 - 27

NAMSS FOCUS

NAMSS' Comment (2013):
"Although the medical staff may have a
stronger voice at the governing body level
through regular consultation with the
medical leadership than through individual
physicians serving on the governing body,
physician representation on the hospital
governing body can be equally effective
for many hospitals. Thus, while NAMSS
commends CMS' proposal to allow medical
staff within a hospital direct consultation
with the governing body, NAMSS
recommends that CMS provides individual
hospitals the option to incorporate direct
physician involvement on the governing
body while having the governing body seek
direct input from the hospital's medical staff
leadership at least twice a year.

staff, or the designee, at least twice during
a fiscal or calendar year. A single governing
body overseeing a multihospital system will
directly consult with the individual responsible
for the medical staff, or the designee, of
each hospital within its system at least twice
during a fiscal or calendar year.

4. Hospital Medical Staff
CMS' Proposed Rule (2013):
"We propose to require that each hospital
must have an organized and individual
medical staff, distinct to that individual
hospital, that operates under bylaws
approved by the governing body and
which is responsible for the quality of
medical care provided to patients by that
individual hospital."

'hospital' for purposes of the single medical
staff requirement. NAMSS requests that CMS
confirms this interpretation.
NAMSS is particularly concerned that
the current proposed single-medical-staff
requirement contradicts and undermines
CMS' expressed intent to provide greater
flexibility to hospitals in designing effective
governance structures. For instance, the
current CoPs expressly permit multihospital
systems to have a unified governing body.
CMS has explained that this will promote
'efficient and effective' governance and can
help hospitals 'achieve significant progress
in quality programs' (77 Fed. Reg. 29034,
29037-38 [May 16, 2012]). However, despite
recognizing the benefits of a unified governing
body in promoting efficient and effective

NAMSS also requests that CMS clarifies
whether this requirement specifically
pertains to the full governing body or
encompasses subcommittees of the
governing body. For instance, if a governing
body has delegated decision-making
authority to a medical staff oversight
subcommittee, would the medical staff
oversight subcommittee's consultation with
the medical leadership at least twice a year
satisfy the new CoP requirement?"

NAMSS appreciates CMS' consideration of
public feedback and will continue to monitor
proposed CoPs changes to ensure NAMSS'
member interests are represented.

CMS' Final Rule (2014):

NAMSS' Comment (2013):

"We are adding a new provision to the
'medical staff' standard of the governing
body CoP. This new provision requires a
hospital's governing body to directly consult
periodically throughout the calendar year or
fiscal year with the individual responsible for
the organized medical staff of the hospital,
or his or her designee. For a multihospital
system using a single governing body to
oversee multiple hospitals within its system,
this provision requires the single governing
body to consult directly with the individual
responsible for the organized medical staff
(or his or her designee) of each hospital
within its system in addition to the other
requirements finalized here. We are also
removing the requirement for a medical staff
member, or members, to be on a hospital's
governing body."
Key Takeaway:
Hospital governing bodies are no longer
required to include medical staff members.
They are instead required to directly consult
with the individual responsible for the medical

"NAMSS is concerned that CMS' proposal to
require each hospital to have its own distinct
organized and individual medical staff
reduces flexibility for multihospital systems
to design and implement system-wide
medical oversight structures that maximize
efficiency and patient safety. CMS has taken
contradictory positions with regard to the
'single medical staff' requirement in October
2011, May 2012, and in the current
proposed regulation and should clarify these
contradictions.
NAMSS also seeks clarification on the extent
of the 'single medical staff' requirement.
CMS refers to 'each hospital.' Does this
mean each entity operating under a single
state hospital license - even if it has multiple
sites of operation? Does this mean each
entity operating under a single hospital
Medicare provider number - even if it
has multiple sites of operation? A multisite
hospital operating under either a single
state license or a single Medicare provider
number should be deemed a single

governance and quality, CMS is denying
multihospital systems the flexibility to
maintain a unified medical staff, which could
help hospital systems achieve the same goals.
CMS expresses a concern that a large
system with a single medical staff 'may not
appropriately be able to address the needs
of each individual hospital in each local
area' (78 Fed. Reg. 9216, 9221 [February 7,
2013]). NAMSS agrees that any medical staff
structure should provide for local medical
leadership of local issues, but disagrees that
such a structure is inconsistent with having a
unified, system-wide medical staff. NAMSS
is aware of multihospital systems that have
developed a medical staff structure that
combines an overarching unified body with
local medical staff leadership. Such a structure
can achieve the benefits of coordination and
efficiency across a system, with local medical
oversight of local issues and concerns.
Multihospital systems should have the
flexibility to design medical oversight
structures that enable them to maximize
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